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.

Pharmacological Management of the Pediatric Patient

Resident: Adam J. Bottrill
Date: 19JAN11
Region: Providence
Article title: Pharmacological Management of the Pediatric Patient
Author(s): Wilson, Stephen DMD, MA, PhD
Journal: Pediatric Dentistry
Page #s: 131-135
Vol:No Date: 26:2, 2004
Major topic: Behavior Management, Sedation, General Anesthesia
Minor topic(s): NA
Type of Article: Conference Paper

Main Purpose: Provide an overview of the various forms of pharmacological management of pediatric dental patients.

Key points in the article discussion:

I. General:

A. Society demands not only efficient, but HUMANE ways of administering behavior management.
B. Only ONE behavior management technique is consistently taught at ALL residency programs in the US... Pharmacological Management (PM).
1. PM is generally divided into two categories: Sedation and GA.
2. Hundreds of articles written about sedation... much less about GA.
C. Factors to be considered when considering PM.
1. Risks
2. Safety Record
3. Extent of dental needs
4. Practitioner competence
5. Professional support for technique
6. Monitoring
7. Cost
8. Venue
9. Parental expectations
10. Child's needs and personality
11. Integration of these factors into MO embraced by profession

II. Sedation Risks and Safety.
A. Major: brain damage and death
B. Minor: vomiting, behavior, extreme physiological parameters
C. COMPLETE med history is imperative.
1. airway issues (snoring etc...)
2. allergies
3. review of systems
4. Only children with very MILD conditions should be considered for sedation.
D. AIRWAY AIRWAY AIRWAY
E. Though pediatric patients have died due to sedation, there is no evidence that suggests death has occurred when practitioners are faithfully following guidelines.
F. It is NOT POSSIBLE to accurately calculate an official safety record WRT sedation. There is no way to generate an accurate number of SUCCESSFUL sedation attempts.

III. PM Cost and Reimbursement issues

A. Significant issue effecting choice of sedation
B. Medicaid covers enough to "break even" in most states.
C. GA is OFTEN covered for "equivalent" medical procedures.
D. So why the disparity???

IV. Training Issues

A. Risk may INCREASE with sedation (when compared to GA) due to lack of training or adherence to sedation guidelines.
B. Dental students are often not trained in deep sedation techniques due to the lack of knowledge and experience of faculty.
C. There seems to be a general attitude of "It won't happen to me" among dentists using sedation.
D. Solutions: MORE TRAINING, Resolution of the financial/political issues associated with GA

V. Professional Issues

A. Subtle professional pressures by medical anesthesiologists for the independence in the roles the roles of operator and anesthetist.
B. The author blames "financial considerations".
C. 2 or more sedation cases costs MORE than one GA case.
D. Controversy over HOM and "voice control"
E. General disagreement and lack of communication between AAP, AAPD and medical anesthesiologists.

VI. Societal and Parenting Issues

A. Parents no longer implicitly trust practitioners
B. Parental expectations are sometimes rediculo.
C. Recent surveys of AAPD members have shown that the general perceived behavior of children has deteriorated over the last few decades.
1. This correlates with the general increase in the necessity of sedation over the past few decades.

VII. Conclusions

A. GA for the healthy fearful child is extremely safe.
B. Some medical specialists are opposed to use of GA outside of the hospital however "little evidence supporting such an opinion is available."
C. PM of the pediatric patient is acceptable and desirable.
D. What is needed:
1. MORE RESEARCH ENDEAVORS
2. Dissemination of accurate information to communities
3. Collaboration of medical and dental organizations.
4. Political and business initiatives.
5. Further efforts to minimize dental disease.

Assessment of article: I'm not a huge fan of the "Conference Paper." Very opinionated and anecdotal. Not really of much use clinically.