Local Anesthesia Affects Physiological Parameters and Reduces Anesthesiologist Intervention in Children Undergoing General Anesthesia for Dental Rehab

Resident: Adam J. Bottrill
Date: 26JAN11
Region: Providence
Article title: Local Anesthesia Affects Physiological Parameters and Reduces Anesthesiologist Intervention in Children Undergoing General Anesthesia for Dental Rehabilitation
Author(s): Watts, Amy K. DDS, MS
Journal: Pediatric Dentistry
Page #s: 414-419
Vol:No Date: 31:5, SEP/OCT 2009
Major topic: Local Anesthesia, General Anesthesia, Children
Minor topic(s): NA
Type of Article: Randomized, parallel-design study
Main Purpose: The purpose of this article was to evaluate the use of intraoperative local anesthetics in pediatric outpatient dental surgery. It assessed physiological stability, as defined by fluctuations in end-tidal CO2, HR, RR and subsequent anesthesiologist intervention.

Key points in the article discussion:

I. General:
A. Pain is both a real emotional and physiological respoonse
B. Research suggests that the use of regional anesthesia can reduce the amount of required inhaled general anesthesia.
C. LA, in conjunction with GA can produce a more hemodynamically stable patient AND control pain in the immediate post-operative period.
D. IDEAL ANESTHETIC AGENT: immobility, amnesia, , sedation, analgesia/nociception, arousal blockade with a pharmacological profile that possesses a wide margin of safety.
E. Currently, no guidelines by either the ASA or the ADA for use of local anesthesia during GA dental rehab. AAPD states that LA "may be used" to reduce pain in post-op period.


II. Methods:
A. Pilot study was conducted for feasability purposes
B. 48 children (mean age of 3.87) undergoing GA
C. Inclusion Criteria
1. 12-84 mo
2. at least one maxillary extraction.
3. rubber dam clamp in maxilla
4. at least one primary tooth needing pulp/crown
5. ASA I or ASA II
D. One dental anesthesiologist used for all GA's
E. Two groups: LA and NON-LA
F. LA administered prior to procedures (for LA group)
G. 2% xylocaine was given in the LA group
H. No patient exceeded 4.4mL of LA
I. Vital sign changes recorded 30 seconds after each procedure.
J. Anesthesiologist intervention was with 10 mg boluses of propofol
K. Intervention if: movement, breath holding, 20% increase in vital signs, ETCO2 <40mm Hg
B. Two groups: LA and NON-LA
C. LA administered prior to procedures (for LA group)
D. Vital sign changes recorded 30 seconds after each procedure.

III. Results/Discussion: (pooled data)
A. NON-LA group: changes in vital signs were statistically significant for two parameters.
1. Post extraction ETCO2
2. Post extraction HR
B. Interference: Different patients have different tolerability for changes in vital signs from baseline.
C. Weaknesses:
1. The exact amount of anesthesia received by each tooth was not able to be controlled.
2. Order of procedures was decided by the dentist.

IV. Conclusions:
A. Patients who were not given intraoperative local anesthesia were more likely to experience vital sign fluctuation requiring anesthesiologist intervention.

Assessment of article: I thought it was an efffective, thorough study. I wish there was more statistical significance to some of the other parameters and procedures. The conclusions seemed to only follow what is already known anecdotally. Despite this fact, it is nice to have an actual article backing up existing practice.

The effect of midazolam premedication on discharge time in pediatric

Department of Pediatric Dentistry
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title:The effect of midazolam premedication on discharge time in pediatric patients undergoing general anesthesia for dental restorations
Author(s): Jason Horgesheimer, DDS, Charles Pribble, DDS, Ralph Lugo, PharmD
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2001. V 23 No 6 491-494
Major topic: Effects of midazolam on discharge time after GA
Main Purpose: To evaluate the effect of oral premed w/ midazolam on recovery times of children undergoing dental restorations under GA

Overview of method of research:
The records of 106 children were retrospectively reviewed at Primary Children’s Medical Center in Salt Lake City Utah. All patients were ASA I or II. 50 children received .5mg oral midazolam approx. 30 minutes before the procedure. 56 children did not receive any premed. All children were mask inhalation induced with either nitrous, sevoflurane, or halothane. Also, all patients were nasotracheally intubated. Things taken into account in the study were time spent in the OR, post anesthesia care in the PACU, and time spent in the same day surgical suite.

Findings:
Oral midazolam is one of the most common pre-medications used in pediatric anesthesia practices today. It effectively decreases anxiety, produces amnesia, and facilitates anesthetic induction. Theoretically, midazolam has the potential to cause post op sedation and delay recovery from GA. However there is no clear consensus about this in the literature.

In this retrospective study there was no significant difference between the groups with respect to time spent in the OR, PACU, or SDS.
Key points/Summary:
Pre-op midazolam does not delay discharge of children undergoing GA.

Assessment of Article:
Good article. Right to the point. It shows that administering oral midazolam approx 30 min prior to anesthesia induction, the child receives the maximum post op benefit of anxiolysis and amnesia while not delaying discharge.

Dental Fluorosis: Chemistry and Biology

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Dental Fluorosis: Chemistry and Biology
Author(s): T. Aoba, O. Fejerskov
Journal: Critical Review of Oral Biology and Medicine.
Year. Volume (number). Page #’s: 2002 V 13, NO 2. 155-170
Major topic: Fluorosis (FL)
Overview of method of research: THOROUGH review

Findings:
Fluoride (Fl) is the most important caries preventative agent in dentistry today. An increase in various fluoride forms and vehicles has caused an increase in mild to moderate FL in many communities. The effect of Fluoride on enamel formation that causes FL in humans is cumulative. This review article was aimed at discussing the pathogenesis of FL in relation to a putative linkage between ameloblastic activities, secreted enamel matrix proteins/multiple proteases, growing enamel crystals, and fluid composition including Ca and Fl ions.

Enamel is very sensitive to free Fl ions. Once Fl is incorporated into the enamel matrix, the ion affects subsequent mineralization process by reducing the solubility of the mineral. Numerous human and animal studies hve proven that enamel hypomineralization in teeth w/ FL is mostly due to the aberrant effects of excess Fl on the rates at which enamel matrix proteins break down, and at which the rate of the by products are withdrawn from the maturing enamel. Any interference with enamel matrix removal could affect crystal growth, resulting in different magnitudes of enamel porosity at the time of eruption. As of right now (2002) there is no evidence that Fl affects proliferation or differentiation of the enamel organ cells, or the production and secretion of enamel matrix proteins/proteases within the dose range that can cause FL in humans.

The article contends that most likely, the Fl ion indirectly interferes with protease activities by decreasing free Ca concentration in the mineralization process. Ca regulation of these activities is extremely important.
Because the cariostatic effect of Fl is not due to its uptake by the enamel during tooth development, it is possible to obtain substantial caries reduction without a risk of dental FL.

Key points/Summary:
FL is caused by long term ingestion of Fl during tooth development. Even very low amounts of Fl intake may result in a low level of FL. The dose-response relationship is linear, and there is no critical threshold for Fl intake below which the effect on enamel will not be seen. Fl exerts its pathogenic role through alteration of Ca activities, and thereby Ca dependent proteases. More research is needed overall

Assessment of Article:
Very long, intense, specific, tedious article filled with an extreme amount of information. I had to read it three times to soak it all in. Biochemistry overload. I hope that the boards will be more general in asking a question about this… hopefully.

Taurodontism in Children w/ Hypodontia and Supernumerary Teeth: A Case Control Study

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Taurodontism in Children w/ Hypodontia and Supernumerary Teeth: A Case Control Study
Author(s): Wayne Kan, BDsc, DClinDent, et al
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2009. V 32 NO 2. 134-140

Major topic: Taurodontism (TD)
Overview of method of research: 120 cases of children w/ TD were selected from a dental schools patient base. 83 of the children had hypodontia, and 37 children had supernumerary teeth. The crown-body root ratios of the permanent first molars of these children were compared with the same teeth in ‘normal’ case controls. The teeth were examined using the Seow and Lai technique. The teeth were outlined on an OPG and were traced by a single examiner.

Findings:
TD was first used to describe a characteristic molar trait seen in Neanderthal fossils. The definition of TD molars is teeth that have a tendency for the body of the tooth to enlarge at the expense of the roots. TD can be found in both primary and permanent teeth. TD can exist as either as an isolated trait or as a feature of multiple system malformation syndromes such as ectodermal dysplasia, Klinefelter syndrome, Down syndrome, trichodento-osseous dyplasia, and x-linked hypophosphatemic rickets, amelogenesis imperfecta and hypodontia. The etiology of TD is still unknown, however it has been proposed that it’s a result of disrupted developmental homeostasis, and involves a delayed invagination of Hertwig’s epithelial root sheath.

Key points/Summary:
In children with hypodontia, only the girls showed a significantly higher tendency for TD compared to the controls. This is likely to be a genetic issue, and possibly related to the x-chromosome. Boys with hypodontia showed a similar prevalence of TD to normal teeth. Children who had multiple missing teeth were significantly more likely to have TD than children who had one tooth missing. Conversely, TD in children with SN teeth was similar to the control group. Teeth with TD showed a higher prevalence of root resorption during ortho treatment, although this observation has not been confirmed. TD teeth also pose issue for endodontic and prosthodontic therapy (never place a post in a tooth with TD). More studies are needed on all of these subjects

Assessment of Article: Simple, basic knowledge article. Good information. Only one examiner makes the results standardized, but it also only gives us one persons view concerning the teeth. Most importantly, things to take away from this article for boards are
1. TD is associated with nonsyndromic hypodontia in girls, but not with nonsyndromic children with SN teeth
2. Children with multiple missing teeth are more prone to TD than a child who is only missing one tooth

Children’s Preference of Benzocaine Gel Versus the Lidocaine Patch

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center - Providence

Article title: Children’s Preference of Benzocaine Gel Versus the Lidocaine Patch

Author(s): Wu & Julliard.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2003. 25:4. 401-405.

Major topic: Topical Anesthetic Preference

Overview of method of research: Scientific Article

Background:
DentiPatch contains 46.1 mg lidociane (20% concentration), comes in unit dose 1cm x 3cm x 2mm patches and is applied after drying with gauze for 2.5 to 5 minutes with a maximum of 15 minutes in adults. Anesthetic effects take place in 5 minutes with maximum effects in 15 minutes. This delivery system has been shown to be effective in adults, but in children has been shown to decrease verbal indicators of injection pain when compared to topical gel.

Purpose:
To compare the pain, acceptance and preference associated with benzocaine gel and lidocaine patch (DentiPatch).

Methods:
This study included pediatric patients at Sunset Park Family Health Center at LMC in Brooklyn, NY with relatively non-contributory medical history, who demonstrated compliance with dental visits and demonstrated the need for bilateral topical anesthetic. These patients were required to have similar or identical treatment on both sides and identical local anesthetic administration on both sides.
On visit #1 the subjects were asked to choose between the 2 methods of topical anesthesia (DentiPatch with whimsical design or cherry flavored 20% benzocaine topical gel). The topical that was not chosen was then to be used at visit #2 which the child was informed of. One operator applied the topical and local anesthetic as well as performed the required treatment. The soft tissue was dried and the appropriate topical anesthetic was applied for 4 minutes with the DentiPatch first being cut in half to reduce the dosage of anesthetic.
2 different scales were used to measure comfort and pain, one subjective and one objective. The subjective scale was completed by the patient before the topical, after topical anesthetic administration and again after the injection if needed. At the first visit, the subjects were asked by the operator why they had chosen that mode of topical anesthesia and after the second visit which mode they liked best and why. The assistants conducting the objective scale were calibrated in 3 sessions with the operator.

Results:
30 subjects between 3 and 12 years old participated; 25 required local anesthetic. One the first visit 24 of 30 subjects chose the DentiPatch. After the second visit 22 preferred the DentiPatch. All 6 patients who originally chose the gel also stated that it was their favorite mode after the second appointment. At the first visit girls seemed to choose their mode based on appearance (61%) and boys because of novelty (88%), but it was concluded that age was the significant factor rather than gender.

Key points/Summary:
The DentiPatch was preferred by most children. Younger children chose the patch because of appearance whereas the older children chose it because of novelty and taste.
There were no significant differences in reported pain, but the objective scale values were higher for the gel than the patch indicating the DentiPatch was more effective in reducing pain.

Assessment of Article:
I thought this article was ok. The sample size was small, but the findings were interesting.

Clinical Solutions for Developmental Defects of Enamel and Dentin in Children

Resident: Roberts

Date: 1/26/11

Author: Shabtai Sapir

Journal: Pediatric Dentistry

Volume: 29 Number: 4

Year: 2007

Title: Clinical Solutions for Developmental Defects of Enamel and Dentin in Children

Discussion

Developmental defects of enamel(DDE) consist mainly of hypoplasia and of diffuse demarcated opacities. Fluorosis, Amelogenesis imperfecta, and even dentinogenesis imperfecta may be considered developmental defects of the enamel. Often times a patient who presents with DDE will complain of poor esthetics, thermal sensitivity, attrition, secondary caries, tooth discoloration, malocclusion and periodontal problems. It is upto the clinician to take into account the patients chief complaint and whatever other complications may present with the condition and treatment accordingly for the best result possible.

Prevention

When possible preventative treatment can an important step in managing a patient with DDE. This consist of early detection, often noted at the early eruptive stages of the 6 year molars as well as along with the anterior incisors. When detected, oral hygiene instruction may include proper toothbrushes and techniques as well as desensitizing toothpaste if necessary. A weekly topical fluoride gel or varnish application and daily sodium fluoride rinse may improve resistance to demineralization, decrease tooth sensitivity, and enhance enamel remineralization as well as post eruptive maturation. The use of a sealant early on may be appropriate when possible. Mechanical preparation of the enamel prior to application is not desirable unless integrity of the enamel has already been compromised

Thoughts about which adhesive system to use

The shear bond strength of resin composite bonded to hypo-mineralized enamel is significantly lower than bonding to normal enamel. Phosphoric acid, most commonly used for enamel etching, may cause more enamel loss than self-etching primers, reducing the adhesion to hypo-mineralized enamel. Self-etching adhesives( which are hydrophilic, bond chemically and micro-mechanically) may offer an alternative that better meets the challenge of adhesion to hypo-mineralized enamel.

Treatment

Treatment depends on the severity of the condition. A definite correlation between color and porosity, mineral content, and depth has been established. Yellow-brown defects tend to be deeper extending all the way to DEJ. Whereas white creamy defects are usually less porous and variable in depth.

mild cases of hypoplasia and fluorosis

Usually no treatment is indicated unless small and minor lesions exist. If this is the case enamel micro-abrasion can be performed but caution must be taken to not remove to much of the surface area compromising the integrity of the rest of the tooth. Fluoride applications and bleaching can also have a positive effect with these cases.

moderate cases of hypoplasia and fluorosis

Micro-abrasion may be considered. When moderately significant tooth structure is removed then a composite restoration should be considered to restore form and function. Self-etching primers are not recommended in moderate and severe fluorosis, as they provide a lower shear bond strength.

severe cases of hypoplasia and fluorosis

Crown restorations with resin composites, polycarbonate crowns, laminate veneers, or porcelain crowns may be indicated in these circumstances. If severe DDE is suspected the earlier the treatment the better the prognosis. For lesions not associated with fluorosis, self etching primer is preferred. When the defects involve proximal surfaces RSC can be very retentive and esthetic, when posterior teeth are involved or the state of hypoplasia is so severe polycarbonate or cast crowns is preferred and has been proven to be more durable. With severe fluorosis and AI a pre-rinse with 5% NaOCL can improve the mechanical and chemical bonding of the adhesive for better results.

Treatment of DI

The primary dentition is usually affected more often than the permanent dentition. Intracoronal restorations and veneers may be considered for anterior teeth. External bleaching has a history of producing positive results. Most posterior teeth are severe and require early restoration with SSC’s. In the anterior dentition RSC may not have good results due to adhesive problems. Anterior permanent teeth that erupt should however be covered with composite until they fully erupt to avoid attrition and then have a RSC, polycarbonate crown placed until a PFM crown can be placed at a later date.

Conclusion

Early detection and preventative measures may go along way to maintaining the health of a compromised dentition. Educating the parents so that definitive action can take place will be necessary for a good long term prognosis.

Factors Associated With Parents’ Esthetic Perceptions of Children’s Mixed Dentition Fluorosis and Demarcated Opacities

Meghan Sullivan Walsh January 23, 2011

Literature Review - St. Joseph/LMC Pediatric Dentistry

Factors Associated With Parents’ Esthetic Perceptions of Children’s Mixed Dentition Fluorosis and Demarcated Opacities

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Factors Associated with Parents’ Esthetic Perceptions of Children’s Mixed Dentition Fluorosis and Demarcated Opacities

Authors: Steven M. Levy, DDS, MPH; John J. Warren, DDS, MS; Barbara Broffitt, MS; Bethany Nielsen, BS

Journal: Pediatric Dentistry

Volume (number), Year, Page #’s; 27:6, 2005, pages 486-492

Major Topic: To present results concerning parent’s overall satisfaction with their children’s teeth with and without fluorosis and demarcated opacities.

Overview of Method of Research: The Iowa Fluoride Study is an ongoing longitudinal study of a cohort recruited at birth in 1992-1995 from postpartum units of eight Iowa hospitals. At the age of 7.7-11.9 years these subjects were given a dental examination and the parents completed a questionnaire to assess their satisfaction with their child’s dentition. The Fluorosis of these subjects was scored using the Fluoride risk index (FRI) dividing teeth into four sections of zones of teeth: 1) Incisal or occlusal table 2) incisal 1/3 3) Middle 1/3 4) cervical 1/3. The scores were evaluated in six separate categories. 1. 0 - no indication of fluorosis 2) 1-questionable fluorosis 3) 2-50% or more of the zone displayed fluorosis 4) 3- displayed pitting staining or deformity 5) 7- non fluoride opacity 6) 9- the surface zone was excluded due to poor visibility/lack of full eruption. Individuals were then classified into 3 different categories. 1) 2 or more teeth with at least one zone with a FRI score of 2 and 3 were considered to have “definitive fluorosis”; 2) a FRI score of 1 or with only one tooth with a score of 2 or 3 were both considered to have “questionable fluorosis” 3) no scores of 1,2, or 3 were in the “none” category. The questionnaire given to the parents contained three questions 1) Which of the following best describes your thoughts overall about the appearance of your child’s teeth? 2) If not ‘very satisfied’ which of the following are you concerned about? (choices included shape, color, alignment, spacing, crowding, speckled/blotchy, other 3) Which of the following best describes your thoughts overall about the color of your child’s teeth?.

Findings: Of the 577 children examined 37% had definitive fluorosis on one or more permanent incisors. 31% were classified as having definitive fluorosis, 54% had questionable fluorosis and 15% had none. Parent’s overall satisfaction decreased with higher fluorosis scores. Among those children with definitive fluorosis 50% of the parents had concerns about the color, as compared to 32% for those questionable fluorosis subjects and 40% for no fluorosis patients. 44% of the children with definitive fluorosis had parents who were concerned about the ‘blotchy’ appearance of their child’s teeth versus 21% of parents with children of ‘questionable’ fluorosis’ and 9% of parent whose children had no fluorosis. There was no significant relationship between occurrence of opacities and parent’s satisfaction with the overall color of their child’s teeth. In addition 60% of parents were concerned with alignment and 44-51% were concerned with crowding.

Key Points: Summary: Parents of children with dental fluorosis were less likely to be satisfied with the overall appearance of their child’s teeth versus parents with children who had no fluorosis. This study does show that fluoride does contribute to esthetic concerns for parents of children with fluorosis.

Assessment of the Article: The Iowa Fluoride Study is a great tool to study the relationship between fluoride exposure and the risks and benefits of intake. While this study did show that fluorosis does pose many esthetic concerns among parents there were many issues I had with this study. First, the age group selected for examination was that of mixed dentition patient which can result in parents having concerns in their child’s dentition for several reasons not necessarily that of fluorosis. A high percentage of parents had concerns with their child’s dentition who showed questionable of no signs of fluorosis. These numbers, while less than those children with fluorosis, show a questionable assessment of a parent’s view of their child’s dentition. In addition, parents were just as concerned with alignment, spacing, crowding, etc. as they were with dental opacities and fluorosis. The study will pose much more sound when these patients are in full permanent dentition and can take a questionnaire based on the assessment of their own dentition.

N2O/O2 versus O2 use during Conscious Sedation

Resident: Swan

Article Title: The Physiological effects of supplemental oxygen versus nitrous oxide/oxygen during conscious sedation of pediatric dental patients

Author: Leelataweewud, et al

Journal: Pediatric Dentistry, Volume (Number): 22:2, 2000
Major Topic: Conscious sedation using an oral narcotic regimen with adjunctive oxygen or nitrous oxide/oxygen

Type of Article: Scientific article

Main Purpose: compare the effects of N20/O2 versus O2 as adjuncts to an oral narcotic regimen during pediatric conscious sedation

Background: The use of N20/O2 as an adjunct during CS is a widely practiced and well-researched technique, although some studies do indicate that N20 use can compromise the airway of a sedated child. Supplemental O2 administration during CS has also been the subject of previous research—the thinking behind it is that supplemental O2 elevates arterial oxygen tension to much higher levels than normal and also increases residual functional capacity, providing an O2 reserve in the case where a child’s breathing slows or stops during sedation. (preventing desaturation, or a drop in SpO2 of 5% from baseline in an immobile, quiet patient.) Studies have supported this use of supplemental O2. Other studies comparing the two techniques have shown no difference in physiologic parameters (PR, SpO2, RR), with better sedation using nitrous.

Overview of method of research: 19 children were included in this randomized double-blind crossover stud. Each child served as their own control by either receiving O2 or N2O/O2 supplementation during two operative visits. The investigators were blinded as to this initial assignment. Baseline vitals were taken for each patient, and all patients were given an oral regimen of 50 mg/kg chloral hydrate, 25 mg hydroxyzine, and 1.5 mg/kg meperidine. 45 minutes after administration, the kids were transferred to the operatory, papoosed, and attached to monitors. Treatment was planned so that each of the two visits would have comparable difficulty and length, but if patients were well-sedated and cooperative, the operator did as much work as possible. PR, RR, SpO2, and end-tidal CO2 were measured every 5 minutes. The PI recorded levels of sedation during the appointments using an AAPD approved subjective scale. The overall sedation outcome was assessed at the end using another subjective scale. Data were statistically analyzed.

Findings: The differences in PR and SpO2 between different visits were not statistically significant, while effect on RR was marginally significant (N2O actually increased RR in this study). There were more desaturation events using N2O/O2, but the difference was not significant (mean of 5.9 events for N2O appts, 3.6 in the O2 group). Level of sedation was higher with the N2O group, and this finding was statistically significant. The final evaluations of the sedations were as follows: with O2 use, 42% excellent, 37 % unsatisfactory, and 21% unsatisfactory. With N2O use, 69%, 26%, and 5% respectively.

Key Points/Summary:
1. No difference in physiologic parameters was noted during treatment.
2. N2O did not increase risk of desaturation but did increase frequency of desaturation events and airway repositioning after desaturation episodes.
3. N2O deepened sedation levels with this narcotic regimen
4. N2O improved sedation outcomes
5. When N2O is used, children should be monitored very closely

Assessment of Article:I had not heard of O2 supplementation during CS, but it appears N2O provides much better sedation as one may assume. The subjectivity of the assessment scales used is a potential limitation, but is the most feasible method of evaluation. I thought it was a good study overall.

Obesity: A Complicating Factor for Sedation in Children

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center - Providence

Article title: Obesity: A Complicating Factor for Sedation in Children

Author(s): Baker & Yagiela.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2006. 28:6. 487-493.

Major topic: Obesity and Sedation

Overview of method of research: Lit Review

Background:
The incidence of mortality of pediatric sedation has been estimated to be 1:250,000. The major cause of serious negative complications is hypoxia and often involves healthy patients. However, patients with compromised respiration are more likely to have complications. Obese patients are considered to have “chronic extrinsic restrictive lung disease” on top of other compromised systems.
In adults a BMI >25 is considered overweight, >30 is obese and 40 or more is morbidly obese. In children, these ranges vary by age and gender (see chart).

Obesity’s Biological Consequences:
Respiratory System: Obesity restricts ventilation by adding excess weight to the thoracic and abdominal cavities making movement of the diaphragm more difficult as well as increasing airway resistance. The functional residual capacity, the amount of gas remaining in the lung after passive expiration, decreases exponentially when BMI increases. These changes are heightened with the use of respiratory depressant medications creating a smaller oxygen reservoir. Obese patients also tend to breathe more rapidly and shallowly which is only further accentuated in pediatric patients who have a higher respiration rate. Increased weight promotes airway narrowing and estimated 5% of obese patients develop obstructive sleep apnea.
Cardiovascular System: Although obesity can have negative effects on the cardiovascular system, cardiovascular complications due to obesity alone during sedation are rare with pediatric patients.
Gastrointestinal System: Obese pediatric patients tend to have a high gastric volume increasing their risk of aspiration. A short neck, minimal movement of the cervical spine and limited mouth opening from fatty cheeks and submental region as well as large tongue can also complicate sedation.

Pharmacokinetics in the Obese:
BMI affects drug absorption, distribution, metabolism and excretion especially lipophilic drugs which include most drugs used for sedation. Intravenous doses of drugs tend to have similar initial effects, but a shorter duration of clinical effect due to redistribution to adipose tissue. Once the administration has stopped, there is a longer elimination half-life causing a delayed complete recovery.
Sedation drugs administered orally also tend to have increased initial effects with an extended clinical duration. Although nitrous oxide has a relatively rapid onset and elimination, recovery time for the obese patient can also be delayed.
Disturbances in liver and renal function can have effects on drug clearance, but sedation after single doses are not usually affected.

Recommendations:
Thorough medical evaluation looking for signs of respiratory disease or cardiovascular disorders as well as range of motion in the neck and jaw. Oral sedation should be carefully monitored and although dosages are typically calculated by total body weight, maximum dosages should be reduced.
Nitrous oxide is a good option while opioids and chloral hydrate should be avoided because of their tendency to cause excessive sedation.
Fasting regulations set by the AAPD should be strictly enforced. Obese patients should be monitored with a pulse oximeter, blood pressure cuff, pretracheal stethoscope, electrocardiogram and capnograph. As hypoxemia is a common complication, patients should be closely monitored post-operatively in a somewhat upright position and not released until they remain awake without stimulation. Post-operative opioid analgesics are to be avoided and lastly, a chest x-ray should be taken if aspiration of stomach contents is suspected.

Assessment of Article:
Me really likey. This article points out a bunch of information that makes sense, but I never thought about before. Very interesting for us as pediatric dentists especially considering the increasing numbers of obese children.

Fasting State and Episodes of Vomiting in Children Receiving Nitrous Oxide for Dental Treatment

Resident: Roberts

Date: 1/19/2011

Article title: Fasting State and Episodes of Vomiting in Children Receiving Nitrous Oxide for Dental Treatment

Author: Kupietzky, Ari

Journal: Pediatric Dentistry

Volume: 30 Number: 5

Year: 2007

Discussion

The pre-procedural fasting (PF) guidelines by the AAPD for use of Nitrous Oxide state that PF is not required for patients undergoing Nitrous Oxide administration (NOA. Conversely they also state that the practitioner may recommend that only a light meal be consumed in the 2 hours prior to the NOA. No controlled study is referenced supporting the recommendations. PF advocates may argue that the foremost adverse reaction associated with NOA is vomiting; thus if a child has eaten prior to the appointment he or she should not be treated. Dentist who argue that fasting is not a concern with NOA might reason that the incidence of vomiting is extremely low and since the patient remains conscious they continue to maintain their protective reflexes intact - unlike deeply sedated patients. They may also reason that unfed children tend to be cranky and combative thus requiring higher levels of nitrous oxide for optimal sedation which then has a greater chance of inducing nausea and vomiting. Another paradox might be that patients who receive NOA on an empty stomach might be more susceptible to nausea and vomiting. One study suggested that nausea and vomiting are a result of hypoxia and over-sedation.

Method and materials

One hundred and thirteen children (64 male, 49 female), ranging in age from 24 to 160 months and a mean weight of 23 kg, participated in this study. Patients were assigned to two operative appointments. One fasting( 6 hours prior for solids 2 hours for clear liquids), and the other not fasting. During the study patients were titrated up-to no higher than 50% nitrous oxide. No appointment lasted longer than 35 minutes.

Results

Vomiting occurred in one subject immediately after cessation of treatment. The 8 yr. old ( did not specify gender) had consumed a heavy lunch following by a late afternoon snack of chocolate pudding 1 hour prior to treatment. Less than 0.5% of the total treatments (1% of the patients), fasting or non fasting, ended in an event of emesis.

Conclusion

Dentist using Nitrous Oxide for minimal sedation purposes should be aware that an episode of emesis is possible. In the event that a patient has nausea, Nitrous oxide should be turned off and oxygen should be restored to 100% delivery until the patient begins to feel normal. If vomiting does occur, the patients head should be turned to the side allowing the vomitus to pool in the cheek until it can be expectorated or suctioned away. According the author, many other studies cited no significant association between non fasting patients and an increased incidence in emesis during an appointment. We as pediatric dentist should consider carefully the risks and benefits involved with completing the procedure at hand and make our decisions accordingly.

Natal and neonatal teeth: review of the literature

Resident: Cho

Author(s): Cunha RF,

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2001. 23. 158-162.

Major topic: Natal teeth, neonatal teeth

Minor topic: Riga-Fede disease

Type of Article: Literature Review

Main Purpose: To present a literature review of the important aspects about natal and neonatal teeth.

Findings:

Natal Teeth: present at birth

Neonatal Teeth: erupt during the first 30 days of life

Riga-Fede Disease: condition caused by a natal or neonatal tooth by rubbing the ventral surface of the tongue during feeding, leading to ulceration

Why are natal and neonatal teeth a concern?

- possibility of being swallowed or aspirated due to great mobility

- interference when breast feeding

- possibility of traumatic injury

There is no difference in prevalence between males and females. There is no conclusive evidence of a correlation between early eruption and systemic condition or syndrome. However, in a 17 year retrospective study of 50,892 records in a hospital in Canada, 15 cases of natal teeth were noted, 5 of whom presented with one of the following: cleft palate, Pierre Robin syndrome, Ellis-van Creveld syndrome, hypocalcemia with fracture of the ribs and rickets, and adrenogenital syndrome with 18-hydroxylase deficiency. The accepted possible cause of natal and neonatal teeth is superficial position of the germ associated with a hereditary factor. The etiology of natal and neonatal teeth needs to be further researched.

Natal and neonatal teeth may be conical and smaller than primary teeth or normal size and shape and opaque yellow-brownish in color. These teeth may be classified into mature (fully developed in shape and comparable in morphology to primary teeth) and immature (structure and development is incomplete). The term mature implies a relatively good prognosis and immature implies a poor prognosis. Histological studies have demonstrated that most of the natal and neonatal teeth are covered with hypoplastic enamel with varying degrees of severity, absence of root formation, ample and vascularized pulp, irregular dentin formation, and lack of cementum formation. Most of the dentin observed was normal dentin except for certain irregular areas.

Natal and neonatal teeth are primary teeth of the normal dentition 95% of the time and supernumerary teeth only 5% of the time. They are located in the lower incisors 85% of the time and erupt as double in 61% of cases. Natal and neonatal teeth, though rarely, can also present as upper incisors, canines, and molars.

Diagnosis of whether a tooth is a supernumerary tooth or primary tooth is determined by radiographic and clinical findings. A supernumerary tooth should be extracted. A tooth diagnosed as a primary tooth should be attempted to be maintained by smoothing the incisal margin or adding composite to the rough incisal margin. However, if the tooth is interfering with feeding or a risk of aspiration or causing trauma to the baby’s tongue/maternal breast, extraction is indicated.

Considerations when extracting a natal or neonatal tooth:

- avoid extraction up to 10^th day of life to prevent hemorrhage (need to wait for commensal flora of the intestine to become established and to produce vitamin K, which is essential to produce prothrombin in the liver)

- consult pediatrician whether vitamin K (delivered IM) needed before extraction

- avoid unnecessary injury to the gingiva

- alert to the risk of aspiration during removal

Since mineralization of natal and neonatal teeth are not complete, the prevention of dental caries is a concern and controlled by good oral hygiene and frequent fluoride application.

Key points/Summary:

1. Natal and neonatal teeth are rare (1:1000 to 1:30,000)

2. Radiographic examination is necessary in order to diagnosis whether it is a supernumerary or primary tooth.

3. Supernumerary natal/neonatal tooth should be extracted. The decision to maintain or extract a primary natal/neonatal tooth is multifactorial. The clinician must consider age of patient and whether vitamin K needs to be administered before the extraction of a natal/neonatal tooth.

4. Periodic follow-up by pediatric dentists is necessary and education of parents is necessary regarding OHI and fluoride.

Assessment of Article: Good article. I learned a lot about natal and neonatal teeth that I did not know before.

Clinical Effects of Nitrous Oxide Conscious Sedation in Children

Meghan Sullivan Walsh January 18, 2011

Literature Review - St. Joseph/LMC Pediatric Dentistry

Clinical Effects of Nitrous Oxide Conscious Sedation in Children

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Clinical Effects of Nitrous Oxide Conscious Sedation in Children

Authors: Milton I. Houpt, DDS, PhD; Robert Limb, DMD; Richard L. Livingston, MD

Journal: Pediatric Dentistry

Volume (number), Year, Page #’s; 26:2, 2004, pages 29-36

Major Topic: Behavior and clinical effects of nitrous oxide sedation on the pediatric patient.

Overview of Method of Research: Fifty-nine children requiring dental treatment ages four to thirteen were selected for this study. The study was conducted at UMDMJ pediatric dental clinic as well as four private practices. The children were divided into three groups; 1) Age 4 and 4 mos to 6 and 4 months, 2) Age 6 and 5 months to 9 years and 3) Age 9 and one month to 13 years. The children were rated with the Frankl scale before treatment and asked questions regarding their preoperative condition. The children were then asked to draw figures from the Binder Visual Motor Gestalt Test. The figures had a range of difficulty and were selected to parallel the abilities of the selected ages. After the children were administered a concentration of 50% nitrous oxide the evaluation was repeated. The children were also asked about their perception of nitrous oxide. Objective signs were recorded before and five minutes after administration of nitrous Oxide. These signs included 1) open or closed eyes 2) tears 3) trancelike expression 4) smile 5) speaking 6) laughing 7) open or closed hands 8) limp legs 9) abducted feet. Subjective symptoms were assessed prior to and 5 minutes after nitrous oxide administration. These questions included 1) How do you feel? 2) Do you feel different? 3) Do you like the funny air? 4) Does your lip feel different 5) How does your head feel? 6) How does your belly feel? 7) How do your fingers feel? 8) How do your toes feel? The following choices were given: ok, tingly, warm, cold, light and heavy. Overall condition choices were good, bad, sleepy and OK. The practitioner then proceeded with the restorative treatment.

Findings: Objective findings showed a high prevalence in open hands, (90%), followed by limp legs, (81%), and abduction of feet, (31%). Smiling occurred at 66% where as trancelike expression occurred at 44%. Subjective symptoms showed a high percentage, 75%, of children reporting feeling good with Nitrous Oxide. Almost all children reported liking Nitrous Oxide (95%) and 85% stated they felt different. A sensation in the lip was reported by 58%. The only statistical different reported with the age groupings was that the older group reported feelings of sleepiness and lightheadedness as well as warmth of fingers and abdomen. With reference to the psychomotor effects and four figure drawings, all three ages groups showed no statistical difference in errors before or after administration of nitrous oxide.

Key Points: Summary: One important finding was the positive attitude expressed by the children when asked if they liked the feeling of nitrous oxide. 86% also reported feeling ‘differently.’ These findings do show a high acceptance rate as well as a high subjective feeling of sedation. In addition, there were many observable clinical signs of sedation with these patients. The only patient group that expressed feelings of lightheadedness and dizziness were the third and older age group. The authors believe this could also be a matter of the younger age groupings not having a clear understanding of these descriptions. To surprise of the authors, the nitrous oxide had little effect on the Visual Motor perception abilities.

Assessment of the Article: I enjoyed this well organized study and article. Often times we assume that children are incapable of being studied subjectively and objectively due to their age and understanding of feelings and and descriptions. I appreciated the fact that the authors attempted to study the pediatric population using terminology and simple age appropriate responses and answers to the effects of nitrous oxide.

01/12/2011 Effect on Behavior of Dental Treatment Rendered under Conscious Sedation and General Anesthesia in Pediatric Patients

Resident: J. Hencler
Date: 01/12/2011

Article title: Effect on Behavior of Dental Treatment Rendered under Conscious Sedation and General Anesthesia in Pediatric Patients
Author: Fuhrer et al

Journal: Pediatric Dentistry V 31/NO 7, NOV/DEC 2009
Major topic: Changes in behavior due to different sedation techniques
Type of Article: Retrospective study/chart review

Main Purpose:
Determine if there were differences in the amount of time it took patients to exhibit positive behavior at follow up visits after receiving dental treatment under general anesthesia (GA) vs. conscious sedation (CS).

Overview of method of research:
This retrospective study examined charts of a private office between 1999 and 2003. Patients presenting before 36 months old for an initial exam who were diagnosed with EEC were included in this study. Following the initial exam, the patients were treated under GA or CS. These patients were followed to determine their behavior at the 6-, 12-, and 18-month recall appointments. The behavior index used in this investigation was the Frankl behavior scale. The CS regimen included chloral hydrate, hydroxyzine, and N2O/O2.

Findings:
39 patients who received treatment under GA were identified and 41 were treated under CS. Patients treated under GA were 3.9 times more likely to exhibit positive behavior at the 6-month recall appointment. Although not statistically significant, a trend towards positive behavior was exhibited at the 12- and 18-month appointments.

Key points in the article discussion:
There are many challenges facing pediatric dentists in behavior management today. The decision of how to treat a pediatric dental patient is influenced by society, marketing, media, communications, technology, and parenting practices. Indications for the administration of sedation include patients who are fearful and anxious; for whom basic behavior guidance techniques have not been successful; who cannot cooperate due to lack of psychological or emotion maturity and/or mental, physical, or medical disability; and for whom the use of sedation may protect the developing psyche and/or reduce medical risk. Although this study found a relationship between sedation type and behavior at future dental visits, 3 other studies cited by this article found no such evidence. Different results may be due to variation in patient ages, sedation protocols, and patient populations between the studies. As this studies results suggest, if patient behavior following treatment under GA consistently exhibits an increased likelihood of positive behavior vs. behavior seen following CS, clinicians may be more likely to select GA over CS for their patient’s initial treatment.

Summary of conclusions:
Patients were more likely to exhibit positive behavior at their 6 MRC following treatment under GA vs. CS. At the 12- and 18-month recall visits, patients were more likely to exhibit positive behavior following treatment under GA; however not statistically significant. Clinicians should consider future behavior in addition to caries when determining treatment modalities for children presenting to their office with dental caries.

Assessment of article:
There may be some bias in these results. Patients were seen by different clinicians at recall appointments. Each clinician could have different interpretations of the Frankl scale, limiting the consistency of the behavior being judged. The study design could have been better. I have not observed a noticeable increase in positive behavior following treatment under GA.

Children Sedated for Dental Care: A Pilot Study of the 24-Hour

Department of Pediatric Dentistry
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title: Children Sedated for Dental Care: A Pilot Study of the 24-Hour Postsedation Period
Author(s): David Martinez, DDS Stephen Wilson, DMD, PhD
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2006. vol 28 No 3 260-264
Major topic: Evaluating children 24 hours post sedation
Minor topic(s): Difference in sedation between chloral hydrate/meperidine/hydroxyzine and midazolam
Main Purpose: Investigate postseadtion events during the first 24 hours after discharge from the treatment facility.

Overview of method of research:
Prospective pilot study. 30 healthy ASA 1 children ranging in age from 2-5 were selected and scheduled for dental sedation. The children were worked up pre operatively with a thorough eval of med/social.dental hx, review of systems, vitals, dental needs, behavior, tonsil size, and sedative regime. 14 Children received a triple combo of chloral hydrate/meperidine/hydroxyzine ranging in dose from 20 to 30 mg/kg, 1 to 2 mg/kg, 1 to 2 mg.kg, respectively. 16 children received midazolam with does ranging from .05 to .75 mg. After the dental procedure was completed and the child was discharged, an investigated called the parents of the patients at the 24 mark. A 20 item questionnaire , including questions about amount of napping, discomfort, food intake, changes in diurnal rhythms, etc was asked to the parents. Responses were entered into an excel spreadsheet and analyzed using SPSS Statistical Package, version 13.

Findings:
It has been suggested that children are often discharge early from treatment facilities following sedations. This may result in an adverse event that may not be detected by non-medical caregivers. This pilot study aimed to quantify any issues arising 24 hours post sedation.
All of the 30 case questionnaires were used in the study. Differences were noted between the triple group compared to the midazolam group with respect to sleeping on the way home, or shortly after getting home. This may be significant because of the parents inability to monitor a sleeping child in car seat while driving, the child may be in a car seat with their head flexed, airway may become compromised.
No difference was found between the groups with regards to eating habits, bathroom habits, vomiting, or post op pain.

Key points/Summary:
There is a chance that an adverse reaction could occur after the child is discharged from the treatment facility. The proper discharge criteria must be met or exceeded to decrease these chances.

Assessment of Article: Good, insightful article that is relevant for us. Limitations include small number of cases, no notes about depth of sedation, pre/post op behavior, age, weight, or what was completed. Overall very well done. More research needed.

Comparison of topical EMLA 5% oral adhesive to benzocaine 20% on the pain experienced during palatal anesthetic infiltration in children

Resident: J. Hencler
Date: 01/19/2011

Article title: Comparison of topical EMLA 5% oral adhesive to benzocaine 20% on the pain experienced during palatal anesthetic infiltration in children

Author: Primosch, DDS, MS, MEd; Roland-Asensi, DDS
Journal: Pediatric Dentistry-23:1, 2001

Major topic: Topical anesthetic
Type of Article: Scientific

Main Purpose:
Compare the pain responses of children during local anesthetic injection at bilateral palatal sites prepared with the topical application of benzocaine 20% oral adhesive (Orabase-B®) versus benzocaine 20% gel (Hurricaine®) or EMLA 5% oral adhesive (EMLA 5% cream on Orabase Plain®).

Overview of method of research:
In the first phase, subjects compared injection pain experience at bilateral palatal sites anesthetized topically with Hurricaine vs. Orabase-B. The second phase was conducted with Orabase-B vs. EMLA 5% manually mixed with Orabase Plain (sodium carboxymethylcellulose oral adhesive). Collected data included the subject’s gender, age, and heart rate (pre-, intra-, and post-injection), pain assessments by the subject using a visual analogue scale (VAS), by the operator using a modification of the Children’s Hopital of Eastern Ontario Pain Scale (CPS), and a post-trial questionnaire comparing overall comfort, taste acceptability, and agent preference. For both the VAS and CPS, the higher the score, the higher the subject’s pain intensity.

Findings:
Forty subjects were selected for the study aged 7-15 years old. When Hurriciane was compared to Orabase-B (Phase I) no significant differences during palatal injection were found for the subject’s pain perception (VAS) and the operator’s assessment of the subject’s pain using CPS. There was an increased mean heart rate during the injection when compared with the mean pre- and post-injection heart rate values but no significant differences in heart rates were shown between the two agents. There were no significant differences in the discomfort reported by the subjects, but Hurricaine was rated slightly better for taste acceptance and agent preference. When Orabase-B was compared to EMLA cream in Orabase plain (Phase II), no significant differences during palatal injection were found for the subject’s pain perception (VAS) and operator assessment of subject’s pain using CPS. There was an increased mean heart rate during the injection when compared with the mean pre- and post-injection heart rate values but no significant differences in heart rates were shown between the two agents. No significant differences in the discomfort reported by the subjects, but subjects expressed greater taste acceptance and agent preference for Orabase-B.

Key points in the article discussion:
The prior application of topical anesthetic helps to alleviate, but does not eliminate, pain associated with needle insertion and anesthetic injection. Widespread belief among patients that topical anesthetics are effective at reducing injection pain may serve to reduce the anticipatory anxiety associated with impending dental injection. The most popular topical anesthetic is benzocaine 20% gel due to rapid onset (30sec), acceptable taste, and lack of systemic absorption. EMLA 5% cream is an acronym for “eutectic mixture of local anesthetics” and contains lidocaine 2.5% and prilocaine 2.5%. Preliminary trials were promising for the effectiveness of EMLA 5% cream on the palatal mucosa of adults, this site has not been tested in children. The palatal site is notorious for its inability to acquire adequate topical anesthesia due to poor drug penetration through highly keratinized tissue. The eutectic mixture found in EMLA cream allows it to be in liquid form at oral temperature and thus facilitates absorption into tissue. The practical disadvantages of EMLA 5% cream intraorally include a bland taste (a pH of 9 may even create a bitter taste), low viscosity with resulting difficulty in retaining it at the desired site, prolonged time of application (5 min vs. 2 min w/ benzocaine), and product cost. This study did not reveal superior effectiveness in reducing injection pain for children using EMLA 5% oral adhesive when compared to benzocaine 20% in gel and adhesive forms.

Summary of conclusions:
EMLA 5% cream in Orabase Plain was equally effective as Orabase-B, which displayed a similar efficacy as Hurricaine. Although all agents tested were equivalent in injection pain response comparisons, Hurricaine had a slight advantage in expressed subject preference and taste acceptance over the other agents. The lack of demonstrated efficacy and subject preference, the necessity to custom mix the cream into an oral adhesive paste, the extended duration of time required for onset of action, the greater potential for complication associated w/ systemic absorption, and the product cost preclude to use of EMLA 5% oral adhesive over other products containing benzocaine 20%.

Assessment of article:
Good article. VAS and CPS scales to report pain perception are subjective and could lead to over or under reporting of pain perception. Everyone has a different threshold for pain. Overall a good study design. Authors could have also tested EMLA 5% cream alone and not mixed into a paste with Orabase Plain. I was surprised by the results of this study.

Bilateral vs Unilateral IAN block anesthesia

Resident: Swan
Article Title: Bilateral versus unilateral mandibular block anesthesia in a pediatric population
Author: College, et al.
Journal: Pediatric Dentistry
Volume (Number): 22:6 2000
Major Topic: Post-operative soft tissue trauma in patients with uni- compared to bilateral block anesthesia

Main Purpose: Address the widely held belief that bilateral mandibular block anesthesia should be avoided when treating pediatric patients because of an increased risk of postoperative soft tissue trauma or other complications.

Overview of method of research: In this study, n=320, which the authors determined to be a sufficient number assuming a 9% difference in trauma frequency between unilateral vs bilateral injection groups. With a difference this large, the results would be statistically significant. Patients for this study were taken from private practices in Colorado and from two postgraduate pediatric clinics affiliated with the University of Michigan (Go Blue.) Any child planned for operative treatment requiring mandibular block anesthesia was eligible for the study. Each child was placed in either the control groups (unilateral block) or experimental group (bilateral) based on the location of necessary treatment. Both written and oral post-operative instructions were given to parents and patients. Parents left the office with a preview of the phone survey questions they would be asked later, in order to better observe their child post-operatively.
“Soft tissue trauma” was defined on the survey as redness and/or swelling on the lip, cheek, or tongue. Other questions asked: difficulty with speech or drooling, time of first meal after tx, and parents’ opinion as to whether the child accepted the numbness sensation or not. The parents were called within two days and the questionnaire was completed with each. Data collection was completed within a week following the appointment.

Findings: Subjects ranged in age from 18 mo. to 18 years, and they were divided into 4 age groups to analyze possible trends. 38 were <4 years old, 121 were 4-7, 93 were 8-11, and 68 were 12+. There was an even distribution of experimental and control patients.
16% of all patients experienced drooling, 32% had some difficulty with speech after treatment. 70% had their first meal within 2 hours after the appointment. A total of 43/320 (13%) experienced soft tissue trauma with either type of anesthesia. 18% of parents thought their children didn’t accept the numbness sensation favorably. There were no statistically significant correlations between the prevalence of soft tissue trauma and any of the parameters surveyed (age, gender, behavior, sedation type, anesthetic type/amount/site)
The highest percentage of trauma (18%) was reported in patients <4 yrs old; the percentage decreased with increasing age. The overall frequency of soft tissue trauma was higher in the unilateral anesthesia groups in 3 of the 4 age groups, (4-7 was the exception). 16% of the unilateral and 11% of the bilateral group experienced trauma. The only statistically significant finding was the incidence of trauma in the <4 age groups. 7/32 experienced trauma and 6/7 were unilaterally anesthetized.

Key Points/Summary: This is the first study to report data on complications of mandibular nerve block in pediatric patients. No significant correlation was observed between postoperative trauma and either unilateral or bilateral nerve block. The reported frequency of soft tissue trauma was much higher than that predicted by previously surveyed pediatric dentists (parents’ subjective observations?) Dentists surveyed reported 4% estimated incidence, while this study found 13% overall. Younger kids had more soft tissue trauma as one might expect. There was a tendency for the unilateral group to experience MORE soft tissue trauma than the bilateral (possibly due to lack of symmetry that exists during unilateral anesthesia). Main take home point: In regard to the factors studied, there is no contraindication to the use of bilateral IAN block when treatment needs dictate.

Assessment of Article: Interesting study posing a question that I’ve wondered myself. There are several obvious limitations that make it hard to widely apply its findings:
1) small number in the smallest age group (38), the only group with statistically significant findings
2) 18 patients were sedated (conscious sedation) during treatment. 14 of them were in the <4 yrs age group. Sedated patients tend to be groggy and want to sleep after treatment, which may lessen their tendency to traumatize their soft tissue. Sedation is a potentially confounding variable.
3) the bilateral group most likely had more work to be done, longer treatment appointments, more time to anesthesia to wear off before dismissing the patient.
4) the study relied heavily on parents’ subjective evaluations of their children’s postoperative state.
Weaknesses aside, this article definitely gave me more confidence to administer bilateral anesthesia.

A Comparison between Articaine HCL and Lidocaine HCL in Pediatric Dental Patients

Meghan Sullivan Walsh January 12, 2011

Literature Review - St. Joseph/LMC Pediatric Dentistry

A Comparison between Articaine HCL and Lidocaine HCL in Pediatric Dental Patients

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: A Comparison between Articaine HCL and Lidocaine HCL in Pediatric Dental Patients

Authors: Stanley F. Malamed, DDS; Suzanne Gagnon, MD; Dominique Leblanc, D Pharm

Journal: Pediatric Dentistry

Volume (number), Year, Page #’s; 22:4, 2000, pages 307-311

Major Topic: Use of Articaine HCL in the pediatric population

Overview of Method of Research: Three identical single-dose, randomized, double-blinded, parallel group, active-controlled, multi center studies were conducted comparing 4% Articaine with 1:100,000 epi to 2%Lidocaine with 1:100,000 epi in patient’s ages 4-79 years old. A subgroup analysis was done on the subjects ages 4 to 13 years old. These pediatric patients were separated into complex and simple dental procedures. The subjects were randomized with a 2.5:1 ratio of the anesthetic use Articaine to Lidocaine. Efficacy of the drug was determined using the VAS scale ranging from 0 (smiley face) “it didn’t hurt at all” to 10 (frown face) “worst hurt imaginable.” The parents explained the scale to the children so they could understand what to do and an investigator also marked his/her opinion of the patient’s pain during the procedure. Vital signs were monitored before and after administration of anesthetic. Adverse effects were followed during the study as well as during follow-up phone calls 24 hours and 7 days after the procedure.

Findings: 50 subjects under the age of 13 were treated with Articaine and 20 subjects under 13 treated with Lidocaine. Patients received comparable volumes of the anesthetic, however higher mg/kg doses were given to the Articaine subjects due to the higher concentration of Articaine (4%) to Lidocaine (2%). VAS scores for Articaine were 0.5 plus or minus 0.18 for simple procedures and 1.1 plus or minus 0.33 for complex procedures. The investigator scores ranged from 0.4 plus or minus 0.14 to 0.6 plus or minus 0.28. VAS scores for Lidocaine were 0.7 plus or minus 0.26 simple and 2.3 plus or minus 2.25 complex. These number indicated that Articaine is an effective local anesthetic for children. No serious adverse effects were noted. 4/50 articaine patients and 2/20 Lidocaine patients reported at least one minor adverse effect including post-procedural pain, headache, injection site pain and accidental injury. One patient received more than the recommended maximum dosage of Articaine but reported no adverse effects. The only adverse effect noted in the Articaine grouping was accidental lip injury. Vital signs were not clinically significant and not associated with any adverse effects.

Key Points: Summary: Articaine 4% with epinephrine 1:100;000 is safe and effective for use on the pediatric population of at least four years of age. In this study no significant difference in pain relief was observed between the Articaine and Lidocaine groups. Time and onset of 4% Articaine is appropriate for clinic use.

Assessment of the Article: Great clean study comparing Lidocaine with Articaine in the pediatric population. There is mention of previous studies recommending use of 4% Articaine as opposed to a lower dosage such a 2% due to less effectiveness of the later concentration but no differences in toxicity when using the higher concentration. In addition the article does mention that Articaine is not for use in patients with known sensitivity to amide-type local anesthetic or with sulfite sensitivity. It should also be used with caution when treating patients with hepatic disease and significant impairments in cardiovascular function. Use of this drug for children under the age of four is not recommended.