Predictors of Intra-Operative and Post-Operative Pain Associated with Routine Dental Procedures in Children: A Systematic Review and Meta-Analysis.

Background: Understanding predictors of pain associated with paediatric dental procedures could play an important role in preventing loss of cooperation, which often leads to the procedure having to be performed under general anaesthesia. Aim: We aimed to identify predictors of intra-operative and post-operative pain associated with routine dental procedures in children. Materials and Methods: A systematic review of observational studies was performed using electronic searches on MEDLINE, EMBASE, PsycINFO, Global Health via OVID, PubMed, Scopus, and SciELO. The NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to evaluate the quality of the included studies, which were meta-analysed to estimate the impact of dental procedures and anxiety on children's pain perception. A meta-regression analysis was also performed to determine the relative effect of predictors on children's pain perception measured as mean differences on a visual analogue scale (VAS). Results: The search identified 532 articles; 53 were retrieved for full-text screening; 6 studies were included in the review; and 4 were eligible for the meta-analysis. The meta-analysis showed the types of procedures that predicted intra-operative pain, with dental extractions being the most painful (Mean VAS Difference [MD] 46.51 mm, 95% confidence interval [CI] 40.40 to 52.62 mm). The meta-regression showed that pain scores for dental extractions were significantly higher than polishing (the least painful procedure (reference category)) by VAS MD = 23.80 mm (95% CI 5.13-42.46 mm, p-value = 0.012). It also showed that highly anxious children reported significantly higher pain scores during dental procedures by a 12.31 mm MD VAS score (95% CI 5.23-19.40 mm, p-value = 0.001) compared to those with low anxiety levels. Conclusions: This systematic review demonstrates that the strongest predictors of intra-operative pain associated with paediatric dental procedures are dental extractions followed by drilling. Children with high anxiety also reported more pain for similar procedures. Tailoring interventions to reduce pain associated with paediatric dental procedures should be a priority for future research, as reducing pain can impact compliance and could reduce the need for general anaesthesia in dental treatment.

Inside the waiting room: process drama and dramatic distancing for involving children in research on dental anxiety.

BACKGROUND: Dental anxiety in children is a major health concern. Process drama adopts distancing techniques that allow children to examine the possible causes of dental anxiety safely and with authority. Using this method to inform paediatric dentistry is novel and could be adopted in other fields where children experience health-related anxiety. METHODS: A 90-minute process drama workshop was conducted in three primary schools in Batley,West Yorkshire. Sixty-three children participated in the study. Sessions were audio-recorded, transcribed and thematic analysis conducted. RESULTS: Four key concepts emerged: 1) Fear of the unknown; 2) Unpleasant sensory experience; 3) Society's perception and portrayal of the dentist and 4) Learnt negative associations with the dentist. CONCLUSION: Process drama offers a novel approach to develop an understanding of dental anxiety in children. It elicits critical insights from a child's perspective and offers a participatory model for engaging children in health research on sensitive issues.

A single-centre investigator-blinded randomised parallel-group study protocol to investigate the influence of an acclimatisation appointment on children's behaviour during N2O/O2 sedation as measured by psychological, behavioural and real-time physiological parameters.

AIMS AND OBJECTIVES: To describe a study protocol of a randomised control trial (RCT) assessing the effectiveness, in reducing dental anxiety, of an acclimatising nitrous oxide sedation (N2O) session prior to actual dental treatment with N2O. MATERIALS AND METHODS: A single-centre investigator-blinded parallel-group RCT conducted in a postgraduate dental hospital in Dubai, United Arab Emirates (UAE). Anxious children requiring N2O (aged 5-15 years) will be randomly assigned to; a study group: children who will have a preparatory N2O trial experience or; a control group: children who will only have N2O explained to them. Treatment with N2O for both groups will start at the second visit. The following outcomes will be recorded: completion of dental treatment, anxiety scores at baseline and after treatment (using the Modified Child Dental Anxiety Scale faces), behaviour of the child (using Frankl Rating Behaviour Scale) and the acquisition of real-time physiological anxiety-related parameters (using E4® electronic wrist devices). RESULTS: The data will be analysed statistically. DISCUSSION: There is a paucity of research regarding dental N2O acclimatising appointments. This RCT will supplement existing literature. CONCLUSIONS: This RCT will report whether prior acclimatising of a child to N2O sedation is effective, or not, in improving dental treatment behaviour.

Anaesthetic efficacy of articaine versus lidocaine in children's dentistry: a systematic review and meta-analysis.

BACKGROUND: Over the last few years, numerous reviews and studies have awarded articaine hydrochloride local anaesthetic (LA) a superior reputation, with outcomes of different studies demonstrating a general tendency for articaine hydrochloride to outperform lidocaine hydrochloride for dental treatment. Nevertheless, there seems to be no clear agreement on which LA solution is more efficacious in dental treatment for children. There is no previous publication systematically reviewing and summarising the current best evidence with respect to the success rates of LA solutions in children. AIMS: To evaluate the available evidence on the efficacy of lidocaine and articaine, used in paediatric dentistry. DESIGN: A systematic search was conducted on Cochrane CENTRAL Register of Controlled Trials, MEDLINE (OVID; 1950 to June 2017), Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCOhost; 1982 to June 2017), EMBASE (OVID; 1980 to June 2017), SCI-EXPANDED (ISI Web of Knowledge; 1900 to June 2017), key journals, and previous review bibliographies through June 2017. Original research studies that compared articaine with lidocaine for dental treatment in children were included. Methodological quality assessment and assessment of risk of bias were carried out for each of the included studies. RESULTS: Electronic searching identified 525 publications. Following the primary and secondary assessment process, six randomised controlled trials (RCT) were included in the final analysis. There was no difference between patient self-reported pain between articaine and lidocaine during treatment procedures (SMD = 0.06, P-value = 0.614), and no difference in the occurrence of adverse events between articaine and lidocaine injections following treatment in paediatric patients (RR = 1.10, P-value = 0.863). Yet, patients reported significantly less pain post-procedure following articaine injections (SMD = 0.37, P-value = 0.013). Substantial heterogeneity was noted in the reporting of outcomes among studies, with the overall quality of majority of studies being at high risk of bias. CONCLUSIONS: There is low quality evidence suggesting that both articaine as infiltration and lidocaine IAD nerve blocks presented the same efficacy when used for routine dental treatments, with no difference between patient self-reported pain between articaine and lidocaine during treatment procedures. Yet, significantly less pain post-procedure was reported following articaine injections. There was no difference in the occurrence of adverse events between articaine and lidocaine injections following treatment in paediatric patients.

Anaesthetic efficacy of 4% articaine and 2% lidocaine for extraction and pulpotomy of mandibular primary molars: an equivalence parallel prospective randomized controlled trial.

AIM: To compare the anaesthetic efficacy for pain and behaviour during treatment with mandibular infiltration using 4% articaine (BI) with inferior dental nerve clock (IDNB) using 2% lidocaine for extraction or pulp therapy in mandibular primary molars. DESIGN: This was equivalence parallel prospective RCT. A total of 98 children aged 5-9 years old were randomly assigned into two groups: BI supplemented by buccal intrapapillary infiltration with 4% articaine; IDNB with 2% lidocaine supplemented with long buccal infiltration. Behaviour during the injection and treatment procedures was assessed using Wong-Baker Facial Rating Scale (W-BFRS), Visual Analogue Scale (VAS), and Frankl Behaviour Rating Scale (FBRS). RESULTS: During the injection phase, the absolute differences in success rates between the two techniques were 0.06 (95% CI: -0.11 to 0.23) for VAS and -0.08 (95% CI: -0.19 to 0.03) for the behaviour of the child (FBRS). FBRS results showed the equivalence of the two, whereas the VAS results showed nonequivalence with the 95% confidence intervals slightly exceeding the equivalence margin (±0.20). W-BFRS success rates were 63.3% for both. During the treatment, VAS results showed similar success rates, demonstrating equivalence between the two as did the results for FBRS. CONCLUSION: The results suggested equivalence in success rates for both anaesthetic techniques during treatment.

The effects of smoothies on enamel erosion: an in situ study.

OBJECTIVES: To measure, in vitro, the pH and titratable acidity (TA) of various soft drinks and to assess the erosive effect of smoothies using an in situ model. METHOD: The in vitro phase of this study included measuring the inherent pH of six different commercially available smoothies, diet coke, and citric acid 0.3% (positive control) using a pH meter. The TA was determined by titration with NaOH. In the second part of the study, an in situ model was used. An upper removable appliance capable of retaining two enamel slabs was constructed and worn by 14 volunteers. The drinks under test were Innocent(®) strawberries and banana smoothie and citric acid. Volunteers were instructed to dip the appliance in the test solutions extra-orally five times daily for 2 min each time for 21 days. Measurements of enamel loss were made by surface profilometry and microhardness. RESULTS: Diet Coke was found to be the most acidic drink (pH 2.61), whereas Innocent(®) mangoes and passion fruit smoothie showed to be the least (pH 3.9). With regard to TA, Innocent(®) blackberries, strawberries, and blackcurrant smoothie had the highest TA requiring 10.8 mol of NaOH to reach pH 7.0, whereas citric acid required only 3.1 mol of NaOH to reach the same pH value. Surface profilometry and microhardness testing revealed that citric acid caused a statistically significantly greater tooth surface loss compared with smoothie after 21-day pH cycling protocol. CONCLUSION: Smoothies are acidic and have high TA levels. Innocent(®) strawberries and banana smoothie had an erosive potential to the teeth. However, its erosive effect was significantly less compared with citric acid after 21-day pH cycling protocol using an in situ model.

Repeat general anaesthesia, a 6-year follow up.

OBJECTIVE: To investigate the number of children who subsequently required further dental general anaesthesia (DGA) following the baseline DGA for exodontia in 1997 over the next 6 year period, and identify any common factors related to these repeat DGAs. DESIGN: A retrospective longitudinal analysis. MATERIALS AND METHODS: Records from a UK teaching hospital for patients who had extractions under DGA within the calendar year of 1997 were identified and analysed. The individual's demographic details, reasons for the baseline DGA, teeth extracted, number of subsequent DGAs, the reasons for repeat DGA and finally any episodes of pain and/or infection after 1997 were recorded. RESULTS: During 1997, a total of 484 children with mean age of 6.35 (ranged between 1 and 16 years) received a DGA for exodontias. The most common reason for the exodontias carried out at this baseline DGA was dental caries and mean number of exodontias was 4.24. Of the total study population 8.9% subsequently had at least one unplanned repeat DGA, with dental caries being a factor in 84% of the cases. Of the subsequently extracted teeth 71.9% were caries free or unerupted at the time of the initial DGA. Of the children who had a repeat DGA, 61% had experienced at least one episode of pain and/or infection subsequent to the first episode of DGA. The pattern of the child's attendance and the recorded experience of oral pain and infection after the baseline DGA in 1997 were variables proved to be strongly associated with the risk of having an unplanned repeat DGA, with the children who were irregular attenders having a four times increased risk. CONCLUSIONS: Two common factors were identified which might predict the potential for a child requiring a repeat DGA; irregular attendance and oral pain and infection.

A clinical evaluation of mineral trioxide aggregate for root-end closure of non-vital immature permanent incisors in children-a pilot study.

The aim of this pilot study was to evaluate the clinical efficacy of mineral trioxide aggregate (MTA) as an apexification material when used in non-vital immature permanent incisors in children. Fifteen children with a mean age of 11.7 years and 17 non-vital permanent incisors were ajudged suitable for inclusion. Standard endodontic procedures were followed and an apical plug of 3-4 mm was created by using MTA after a calcium hydroxide intracanal dressing had been applied for at least 1 week. Final obturation was completed by using thermoplastisized Gutta-Percha (Obtura II) at least 1 week following MTA placement. Subjects were reviewed clinically and radiographically at 3-month intervals. Mean follow-up time for MTA was 12.53 months (+/-2.94 SD). Of the total of 17 teeth treated, MTA placement was considered to be adequate in 13 teeth. The procedure showed clinical success in 94.1% of the cases, radiographic success was found to be 76.5% and in further three cases (17.6%) the outcome was considered to be uncertain. This is one of the very few studies that have reported the out coming of MTA as an apexification material in children with non-vital teeth and incomplete root development. However, larger clinical studies are required to evaluate the long-term success of this procedure.

Early childhood caries--a review.

UNLABELLED: Early childhood caries (ECC) is rampant caries of the primary dentition of infants and toddlers. It represents a serious problem in dentistry as it progresses rapidly and affects young children. There is a need to identify risk factors for ECC so that targeted, cost-effective interventions can be designed. The literature indicates that immediate intervention is necessary to prevent further dental destruction, as well as more widespread health problems. CLINICAL RELEVANCE: Currently, some 4 out of 10 children starting school have decay in their primary dentition. It is prudent for dentists who diagnose ECC to provide therapy or, if treatment is not possible as a result of the young age of the child and limited co-operation, then it is important to refer the patient to an appropriately trained individual for therapy.

Development of acute Henoch-Schönlein purpura subsequent to endodontic treatment.

BACKGROUND: Henoch-Schönlein purpura (HSP) is an inflammatory disorder of unknown origin that is characterized by IgA-dominant immune complexes in smaller blood vessels. It results in a triad of symptoms, including a purpuric rash on the lower extremities, abdominal pain or renal involvement, and arthritis. Any of the triad may be absent, however, which often leads to confusion in diagnosing the condition. Cases of acute HSP developing subsequent to dental treatment have not been previously reported in the dental literature. CASE REPORT: This study reports the unusual case of a 14-year-old female who developed acute HSP following endodontic treatment. CONCLUSION: Treatment for this condition is supportive and children affected by this disorder need close follow-up of their renal status.

Paediatric dentistry in the new millennium: 5. Clinical prevention: the role of the general dental practitioner.

Prevention of caries underpins all dental care provided to children. This paper reviews the scientific basis of current techniques for dental prevention. It provides guidelines for the identification of children who are at high and low risk and considers the most appropriate preventive strategies for these children.

Paediatric dentistry in the new millennium: 3. Use of inhalation sedation in paediatric dentistry.

Provision of General Anaesthesia is now limited and restricted to the hospital setting. Sedation for paediatric patients is an essential tool in anxiety management and is used as an adjunct to behaviour management. Inhalation sedation with nitrous oxide/oxygen sedation to reach a plane of relative analgesia may be administered easily and safely to children in general dental practice and is a potential alternative to general anaesthesia.

Paediatric dentistry in the new millennium: 2. Behaviour management--helping children to accept dentistry.

Children's dentistry can be a challenge for both the patient and the dentist. The way a dentist interacts with the child patient will have a major influence on the success of any clinical or preventive care. In order to deliver high-quality dentistry to a child whilst also developing a positive attitude towards dental health, the dentist should have a good understanding of the factors that might affect the behaviour of children in the dental setting. A working knowledge of strategies to minimize anxiety and make positive behaviour more likely is essential, as is a grasp of how best to deal with anxiety or negative behaviour.

Paediatric dentistry in the new millennium: 6. Dental anomalies in children.

Developmental defects of the human dentition are not uncommon and can adversely affect the physical and psychological health of children. This paper reviews briefly the most common dental defects that can occur during childhood and discusses in more detail defects of enamel and dentine. Guidelines are provided for clinicians to identify children who deviate from normal dental development in order to provide appropriate interventions or make appropriate referrals.