Shamuilov El-Nathan
5th year, group 16SEDATION IN PEDIATRIC DENTISTRY: A SYSTEMATIC
REVIEW
Master’s Thesis
Supervisor
Sandra Žemgulytė
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF ODONTOLOGY
CLINIC FOR PREVENTIVE AND PEDIATRIC DENTISTRY
SEDATION IN PEDIATRIC DENTISTRY: A SYSTEMATIC REVIEW
Master’s thesis
The thesis was done
by student ... Supervisor ... (signature) (signature)
... ... (name surname, year, group) (degree, name surname)
... 20…. ... 20…. (day/month) (day/month) Kaunas, 2017
EVALUATION TABLE OF THE MASTER’S THESIS
OF THE TYPE OF SYSTEMIC REVIEW OF SCIENTIFIC LITERATURE Evaluation: ... Reviewer: ...
(scientific degree. name and surname)
Reviewing date: ...
No. MT parts MT evaluation aspects
Compliance with MT requirements and evaluation Yes Partiall y No 1 Summary (0.5 point)
Is summary informative and in compliance with
the thesis content and requirements? 0.3 0.1 0
2 Are keywords in compliance with the thesis
essence? 0.2 0.1 0 3 Introduc-tion, aim and tasks (1 point)
Are the novelty, relevance and significance of the work justified in the introduction of the thesis?
0.4 0.2 0
4 Are the problem, hypothesis, aim and tasks
formed clearly and properly? 0.4 0.2 0
5 Are the aim and tasks interrelated? 0.2 0.1 0
6 Selection criteria of the studies, search methods and strategy (3.4 points)
Is the protocol of systemic review present? 0.6 0.3 0
7
Were the eligibility criteria of articles for the selected protocol determined (e.g., year, language, publication condition, etc.)
0.4 0.2 0
8
Are all the information sources (databases with dates of coverage, contact with study authors to identify additional studies) described and is the last search day indicated?
0.2 0.1 0
9
Is the electronic search strategy described in such a way that it could be repeated (year of search, the last search day; keywords and their combinations; number of found and selected articles according to the combinations of keywords)?
0.4 0.1 0
10
Is the selection process of studies (screening, eligibility, included in systemic review or, if applicable, included in the meta-analysis) described?
11
(3.4 points)
Is the data extraction method from the articles (types of investigations, participants, interventions, analysed factors, indexes) described?
0.4 0.2 0
12
Are all the variables (for which data were sought and any assumptions and simplifications made) listed and defined?
0.4 0.2 0
13
Are the methods, which were used to evaluate the risk of bias of individual studies and how this information is to be used in data synthesis, described?
0.2 0.1 0
14 Were the principal summary measures (risk
ratio, difference in means) stated? 0.4 0.2 0
15 Systemiza-tion and analysis of data (2.2 points)
Is the number of studies screened: included upon assessment for eligibility and excluded upon giving the reasons in each stage of exclusion presented?
0.6 0.3 0
16
Are the characteristics of studies presented in the included articles, according to which the data were extracted (e.g., study size, follow-up period, type of respondents) presented?
0.6 0.3 0
17
Are the evaluations of beneficial or harmful outcomes for each study presented? (a) simple summary data for each intervention group; b) effect estimates and confidence intervals)
0.4 0.2 0
18
Are the extracted and systemized data from studies presented in the tables according to individual tasks?
0.6 0.3 0
19
Discussion (1.4 points)
Are the main findings summarized and is their
relevance indicated? 0.4 0.2 0
20 Are the limitations of the performed systemic
review discussed? 0.4 0.2 0
21 Does author present the interpretation of the
results? 0.4 0.2 0
22
Conclusions (0.5 points)
Do the conclusions reflect the topic, aim and
tasks of the Master’s thesis? 0.2 0.1 0
23 Are the conclusions based on the analysed
material? 0.2 0.1 0
25
References (1 point)
Is the references list formed according to the
requirements? 0.4 0.2 0
26
Are the links of the references to the text correct? Are the literature sources cited correctly and precisely?
0.2 0.1 0
27 Is the scientific level of references suitable for
Master’s thesis? 0.2 0.1 0
28
Do the cited sources not older than 10 years old form at least 70% of sources, and the not older than 5 years – at least 40%?
0.2 0.1 0
Additional sections, which may increase the collected number of points
29 Annexes Do the presented annexes help to understand the
analysed topic? +0.2 +0.1 0
30
Practical
recommen-dations
Are the practical recommendations suggested
and are they related to the received results? +0.4 +0.2 0
31
Were additional methods of data analysis and their results used and described (sensitivity analyses, meta-regression)?
+1 +0.5 0
32
Was meta-analysis applied? Are the selected statistical methods indicated? Are the results of each meta-analysis presented?
+2 +1 0
General requirements, non-compliance with which reduce the number of points
33
General
require-ments
Is the thesis volume sufficient (excluding annexes)? 15-20 pages (-2 points) <15 pages (-5 points)
34 Is the thesis volume increased
artificially? -2 points -1 point
35 Does the thesis structure satisfy the
requirements of Master’s thesis? -1 point -2 points
36
Is the thesis written in correct
language, scientifically, logically and laconically?
-0.5 point -1 points
37 Are there any grammatical, style or
computer literacy-related mistakes? -2 points -1 points
38
Is text consistent, integral, and are the volumes of its structural parts
balanced?
-0.2 point -0.5 points
*Remark: the amount of collected points may exceed 10 points. Reviewer’s comments: ___________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _________________________________________ ___________________________
Reviewer’s name and surname Reviewer’s signature
38 General
require-ments
Is text consistent, integral, and are the volumes of its structural parts
balanced?
-0.2 point points-0.5
39 Amount of plagiarism in the thesis. >20%
(not evaluated)
40
Is the content (names of sections and sub-sections and enumeration of pages) in compliance with the thesis structure and aims?
-0.2 point -0.5 points
41
Are the names of the thesis parts in compliance with the text? Are the titles of sections and sub-sections
distinguished logically and correctly?
-0.2 point -0.5 points
42 Are there explanations of the key terms
and abbreviations (if needed)? -0.2 point
-0.5 points
43
Is the quality of the thesis typography (quality of printing, visual aids, binding) good?
-0.2 point -0.5 points
TABLE OF CONTENTS
SUMMARY………..………8
INTRODUCTION………..……9
1. MATERIAL AND METHODS ………..……….12
1.1 Literature search strategy ………12
1.2 Inclusion and exclusion criteria……….………..12
2. RESULTS………..………...14
2.1 General mechanism of medication used for sedation……….………...19
2.2 Behavior scales used to evaluate the effect of sedation in children……….……….21
3. DISCUSSION……….……..…….23
4. CONCLUSION……….25
5. REFERENCES………..26 ANNEXES………...
SUMMARY
Objective: Aim of systematic review was to search and analyze the current publications related to
selected topic. Moreover, to find out the main medications and its dosage, different methods of sedation, applied behavior scales to evaluate the effect of sedation, potential side effect and success rate of sedation.
Material and methods. A systematic review was carried out to identify relevant studies reporting
data on various sedation methods applied in pediatric dentistry. The data was extracted from the selected papers. The following key words or their combinations were used during searching conscious sedation, pediatric patient, dental treatment and children behavior. The search was performed through “PubMed” and was restricted to English language articles, published from 2011 to 2016.
Results. A total 114 of articles were identified after initial search and 12 publications were enrolled
in this systematic review.
Conclusion. Sedation allowed changing negative patients’ behavior. Many different medications
such as midazolam, ketamine, nitrous oxide, dexmedetomidine were used to induce different levels of sedation. While different behavior scales were used to evaluate the improvement of patient behavior during procedures in carried out studies. Usually success of sedation was reported when patients permitted to accomplish dental procedures, whereas some studies were focused more on possible side effect after procedure.
Key words: conscious sedation, pediatric patient, dental treatment, children behavior
Abbreviations:
Per-os- Orally taken medications IN- intranasal taken medication
IV- intravenously administered medication TM- transmucosal way
INTRODUCTION
Sedation in dentistry refers to the use of pharmacological agents to calm and relax a patient prior to and during a dental appointment. The pharmacological agents usually belong to a class of drugs called sedatives, which exert their action by depressing the central nervous system, specifically those areas concerned with conscious awareness.
Delivering dental care to young patients can be very challenging due to fear of pain and rejection to stress situations. A significant number of children are anxious with respect to dental treatment with world-wide studies having suggested that between 3% and 43% of children exhibit dental anxiety [1].Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive and behavioral components. According to the Rachman’s pathway (1974), dental anxiety can be caused by direct conditioning, family learning, given information. When anxiety becomes excessive, it may fall under the classification of an anxiety disorder [2]. The most fearful dental procedures for children appear to be those that are invasive, such as injections and the use of “the drill”. Fear is generally regarded as a physiological, behavioral and emotional response to a feared stimulus. It is commonly encountered in patients receiving dental treatment and also is a syndrome causing major problems for both dentists and patients. In dental practice, a fear could be the main reason for missed or cancelled dental appointments. When behavioral management alone is unfortunately not sufficient for immature, fearful and anxious, medically and physically disabled children, who can be more compassionately be managed with sedation or general anesthesia [3]. Conscious sedation for pediatric dental treatment has shown success rates varying between 26.7% [4] and 95.0% [5], which are primarily influenced by the characteristics of the child, sedative regimen, type of dental procedure, and methods for assessing the child’s behavior.
There are different levels of sedation; it can be classified as a minimal, moderate and deep according to the depression of patient’s consciousness. Conscious sedation is a drug-induced depression of consciousness during which patients responds to verbal commands, either alone or accompanied by light tactile stimulation. Furthermore, cardiovascular and respiratory function is usually maintained. Deep sedation is not recommended for dental procedures, as it is essentially not safe practicedue to its associated increased level of morbidity and mortality. General anesthesia is defined as a drug-induced state in which patients do not have a purposeful response to stimulus, they lose their reflexes and their ability to protect their own airways, and there can be respiratory and cardiovascular depression [6].
Sedation drugs can be can be administered through various ways such as oral, inhalation, nasal, intramuscular, subcutaneous and intravenous. Most popular route of administration is oral. Oral sedation is notoriously unpredictable and frustration often arises when children refuse to accept the sedative medication. On the other hand, placement of an intravenous cannula for parenteral sedation can be traumatic to children as well. Intranasal administration is usually simple, relatively painless, and requires less patient cooperation, but it has been associated with mucosal irritation. This may lead to coughing, sneezing, crying and the expulsion of part of the dose [7].Furthermore, complications such as nausea, vomiting, and hypoxia are the most common.
In order to achieve a proper sedation level, child’s behavior must be observed as well. The behavior is another important factor which results in effectiveness of the sedation. In fact, there is a relation between children’s challenging dental behavior requiring sedation and permissive parenting style. However, there is a lack of knowledge on how parenting affects children’s behavior during procedural sedation [8].
A variety of different behavior scales such as Houpt sedation rating scale, Ohio State University behavior rating score, University of Michigan sedation scale (UMSS), Frankel Behavioral Rating Scale and Venham anxiety/ behavior scale, Behavior/response to treatment (ease of treatment completion) rating scale, Mask acceptance scale, Modified observer assessment of alertness and sedation scale and others can be used to evaluate the effectiveness and success of sedation in studies.
Aim: To search and analyze the publications related to selected topic and to find out the main
medications and its dosage, different methods of sedation, applied behavior scales to evaluate the effect of sedation, potential side effect and success rate of sedation.
Objectives:
1. To search and select the publications for analysis according to the inclusion and exclusion criteria.
2. To identify the most proper medications and its dosage used for sedation in children, possible
outcomes and success rate.
4. To compare the results of different carried out studies which were analyzed in this systematic
1. MATERIAL AND METHODS
1.1 Literature search strategy
Literature was selected through “PubMed”. In this website a variety number of articles can be found according the key word/ phrase that should be typed in the search box. The key words that were: conscious sedation, pediatric patient, dental treatment. The comprehensive search was restricted to English language articles, published from 2011 to 2016. In the results it was shown approximately 114 publications (abstracts). If full publications were not accessible without purchasing, they were excluded. 40 articles were analyzed, of which 12 consistent with the subject of this review were qualified. Citations were read and verified. Articles related to the theme were qualified. After all information’s having collected and exclusions that have been made, the gathering information was sufficient and efficient for the research project. One investigator carried out the selection and evaluation of articles.
According to the PRISMA guidelines, we conducted an electronic search using MEDLINE (PubMed) database and google scholar to locate articles concerning Sedation in pediatric dentistry (Figure 1).
1.2 Inclusion and exclusion criteria
1.2.1 Inclusion criteria for the selection were the following:
-Publications written in English language. -Studies performed on humans only.
-Articles familiar to topic "Sedation in Dentistry"
-Articles that specify the sedation method and patient’s behavior scales. -Participants are under 18 year old.
-Randomized /non randomized controlled clinical studies and prospective/retrospective observational studies
1.2.2 Exclusion criteria for the selection were the following:
- Systematic review and review articles. - Conference proceedings.
- Commentaries. - Practice guidelines.
-Studies performed on animals.
Figure 1 illustrates by a flow chart the process of filtering (PRISMA flow diagram).
Records identified through database searching (n = 114) Sc re ening Inc lu de d El igi b il it y Id entif ic
ation Additional records identified through other sources
(n = 0 )
Records after duplicates removed (n =0)
Records screened
(n = 40) Records excluded (n = 24)
Full-text articles assessed for eligibility
(n =16)
Full-text articles excluded, with reasons
(n =4) Studies included in qualitative synthesis (n =12) Studies included in quantitative synthesis (meta-analysis) (n =0 )
2. RESULTS
This systematic review included 13 articles published between 2011 and 2016. Of the all included studies, 3 were randomized, 5 prospective studies, 3 scientific report and 2 survey. The sample size of the studies ranged from 16 to 472, whereas participants age varied from 1 to 17year old. Most common age groups were between 2-6 years. The most prevalent size of sample varied from approximately 35 to 100 patients. Based on the literature, results focused on the following aspects administered medication, differences among chosen dosage of medication, possible side effect and sedation’s success rate(Table 1),different behavior scales used to evaluate effectiveness of sedation (Table 3). The general mechanism of used medication is presented in Table 2.
Upon analyzing the different sedative used drugs, it appears that midazolam (concentration- 0.5mg/ kg) was the most prevalent medication used for sedation. Consequently, it was chosen 7 times in analyzed 13 studies; moreover midazolam was administered orally in 4 studies and intranasal in 3 studies, respectively. All of the studies showed that midazolam can be used safely and effectively to induce mild or moderate sedation with a success rate of 64, 3% [9].
Hydroxyzine (1mg/kg) was chosen as sedative drug in 4 studies. It was used mainly in combination with other medications (chloral hydrate, midazolam). It was administered orally in 2 studies, whereas the way of administration was not mentioned in 2 others. This drug proved to be a highly effective sedative in all of these studies.
Dexmedetomidine (1-5 µg.kg−1) was used in 5 studies. In most of the studies it was administered intranasal. The drug was shown great sedation’s properties varies from 58%-80% [9, 10].
Three articles assessed the use of Ketamine (5-8mg/kg) always per os. This drug used in combinations with Dexmedetomidine had a great effectiveness.
Nitrous oxide (conc. 30% -70%) has a sufficient sedative efficacy in almost 86.3% of cases (p=0.010). (11)
Drugs such as chloral hydrate in concentrations of 50mg/kg administered orally, fentanyl 200mcg-400mcg and Meperidine showed also some minor effectiveness in sedation, but less compared to midazolam, Dexmedetomidine and Hydroxyzine.
Table 1. Main characteristics of analyzed studies.
Researcher Type of study Number
o f
patients
A g e (years)
Medications Side effect Outcome
Galeotti A et al., 2016 A n observational survey 472 4-17 y N i t r o u s oxide(N2O)- f r o m 3 0 % until desired % Hypersedat i o n , Respirator y disorder, Headache, Hyperexcit a b i l i t y , N a u s e a , vomiting S u c c e s s - 8 6 . 3 % cases. A d v e r s e e f f e c t - 2.5%. (p= 0.010). Silay E et al., 2012 Prospective study 105 2-12 y D o r m i c u m 0.5mgkg-IN Midazolam IV- 1.5mg L i m i t e d movements ,crying’s, difficulties i n swallowing N o significant differences Hitt JM. et al., 2014 Prospective, n o n -comparative study 20 3-7 y Dexmedetom idine 2 µg/ k g - I N ; Sufentanil 1 µg /kg-IN, after 30 min N a u s e a , vomiting S u c c e s s - 100% Ritwik P et al., 2013 Prospective study 52 2-10 y Meperdine/ Hydroxyzine - 40 children Midazolam o n l y - 6 children P a i n , vomiting, f e v e r , s l e e p i n g , s n o r i n g a f t e r procedure, difficulty in waking u p , irritable N o significant differences (P=1.000) H a b e r l a n d CM. et al., 2011 Observationa l s i n g l e -blinded study 35 2-7 y R e g i m e n * 1,2, 3, 4.
Ghajari MF et al., 2014 Double blind c r o s s o v e r randomized study 16 2-6 y 1s t g r o u p : Midazolam, 5mg/kg-per o s hydroxyzine 1 m g / k g (MH) 2n d g r o u p : C h l o r a l h y d r a t e 50mg/kg-per o s , hydroxyzine 1 m g / k g (CHH) Not given S e d a t i v e s u c c e s s r a t e w a s 64.3% in c a s e s o f M H , s e d a t i v e s u c c e s s r a t e w a s 33.3% in CHH (P=0.046) Done V et al., 2016 30 3-9 y Midazolam 0.5mg/kg-per o r w i t h N2 O(30%)-O2 ; Ketamine 5mg/kg-per os with N2 O(30%)-O2 S l i g h t l y b e t t e r e f f e c t i n midazolam - N 2 O - O 2 combinatio n (p >0.05) Peerbhay F el al., 2016 T r i p l e -b l i n d e d randomized c o n t r o l l e d trial 100 4-6 y 1s t g r o u p : lidocaine(0,5 %) sprayed i n e a c h nostril , after 3-4 min IN application of 0,5mg/kg midazolam 2n d g r o u p : lidocaine(0,5 %) sprayed i n e a c h nostril , after 3-4 min IN application of 0,3mg/kg midazolam 3 0 % ; s n e e z i n g , 1 2 % ; b u r n i n g sensation, 9 % ; coughing, 4%. Not given
Singh C et al., 2014 Triple blind randomized study 112 3-10 y G r o u p 1 : Ketamine 8 mg*kg (K), Group 2, 3, 4 : Dexmedetom idine 3µg*kg-1, 4µg*kg-1, 5 µ g * k g - 1 , respectively. Vomiting S e d a t i o n success in 58-78,5 % ( P =<0.001) Antunes DE et al., 2016 Prospective study( baseli ne and three f o l l o w u p visits) 56 <4 y C o n t r o l group (I)-no sedation G r o u p I I -m i d a z o l a -m ( 1 m g / k g , max. 20 mg) per os; Group III-m i d a z o l a III-m (0.5 mg/kg, maximum 20 mg) and ketamine (3 mg/kg dose, max. 50 mg) per os G r o u p I V- g e n e r a l a n e s t h e s i a (sevoflurane, p r o p o f o l , f e n t a n y l , premedicatio n - midazolam Not given G r o u p I - 2.9 times more likely q u i t e b e h a v i o r t h a n a t b a s e l i n e (p=0.017) Group II- 4.3 times more likely (p=0.004) G r o u p I and IV- no significant r e s u l t s (p>0.05)
Regimen* 1: chloral hydrate 50 mg/kg + meperidine 0.5 mg/kg + hydroxyzine 1 mg/kg per os. Regimen* 2: Fentanyl 200 mcg (20–30-kg patients) or 400 mcg (>30-kg patients) -TN + Hydroxyzine 1 mg/kg per os
Regimen* 3: Hydroxyzine 3 mg/kg per os
Regimen* 4: Midazolam 0.3–0.7 mg/kg + Hydroxyzine 1 mg/kg –per os; Nitrous oxide- IN with a conc. of 70% N2O and 30% O2 at a 3 L/min flow rate, for the duration of the procedure.
Group** MK: 0.4 ml IN placebo (normal saline) followed at 30 min by per OS administration of midazolam 0.5 mg/kg and 5 mg/kg ketamine mixed in 30 ml mango juice.
Group** DX received IN Dexmedetomidine at 1 µg/kg. To make final volume 0.4 ml, normal saline was added, followed at 30 min by oral administration of 30 ml mango juice.
Group** C: IN drops of 0.4 ml saline followed at 30 min by oral administration of 30 ml mango juice. Bhat R et al., 2016 Randomized double blind study 54 1-6 y 2 g r o u p s : Group D: 1 µ g . k g − 1 Dexmedetom i d i n e I N Group DK: 1 µ g . k g − 1 Dexmedetom idine and 2 m g . k g − 1 ketamine IN Not given S e d a t i o n successful in 80% P <0.05 Malhotra PU et al. 2016 D o u b l e b l i n d e d randomized c o n t r o l l e d study 36 3-9 y G r o u p * * MK, DX, C. Not given P <0.05)
2.1 General mechanism of medication used for sedation
Nowadays there are different kinds of medications used for achieving proper sedation level. They can be administered in different ways. Each of them has its own effect and mechanism of action. In the following table we can see the most popular one used and their mechanism of action. (Table 2)
Table 2. General mechanisms of medication used for sedation.
DRUGS Mode of Action
Midazolam Activation of alpha-1 subunits of GABA-A receptors whereas anxiolytic effect is due to alpha-2 subunit activity. Alpha-1 containing GABAA receptors are the most numerous accounting for 60%
Nitrous Oxide A rapid onset of action is therefore coupled with a rapid recovery period. N2O provides its anesthetic properties through the non-competitive inhibition of the excitatory NMDA subtype glutamate receptors
Ketamine It interacts with N-methyl-D-aspartate (NMDA) receptors, opioid receptors, monoaminergic receptors, muscarinic receptors and voltage sensitive Ca+ ion channels. Unlike other general anesthetic agents, ketamine does not interact with GABA receptors
Dexemedetomidine Activation of these receptors in central nervous system leads to inhibition of symphatic activity, which causes reduction in blood pressure and heart rate, sedation and anxiolytics
Hydroxyzine Hydroxyzine also has antiemetic capacity while being effective for sedation in certain cases with no complication being reported over its use. It sedation effects lasts very long especially for long dental treatment procedures. When taken together with midazolam, it enhance sedative effects of midazolam
Fentanil Characterized by a rapid onset and relatively short duration of action. These pharmacological properties may lead to improvement of intraoperative analgesia and enhanced duration of postoperative analgesia
Chloral hydrate Has high gastrointestinal absorption and metabolized to trichloroethanol and trichloroacetic acid in liver, erythrocytes, and other tissues rapidly
2.2 Behavior scales used to evaluate the effect of sedation in children
Behaviors of children were expressed by different scales. These scales are presented in Table3. The Houpt sedation rating scale, which was chosen 2 times in the following studies [12, 13] showed us a range from aborted to excellent treatment. The Ohio State University behavior rating score appears in 2 studies. It shows us the physical activity of the child, if he is moving, crying [14, 15].
The University of Michigan sedation scale (UMSS) shows us the deepness of achieved sedation from awake/alert condition to Unarousable state [13].
Accepting or ignoring the treatment was analyzed by the Frankel Behavioral Rating Scale. It is expressed by ratings, from 1 to 4, from definitely negative to definitely positive. [16]. Venham anxiety/ behavior scale, which is shown in 2 studies, [17,11] expresses the cooperation of child regarding the treatment, ranges from 0 which is total cooperation to protesting against any kind of treatment 5.
Behavior/response to treatment (ease of treatment completion) rating scale shows us how the behavior gets affected by treatment, in a scale of 5 which means quit and cooperative to 1 which is uncooperative [9].
Mask acceptance scale (MAS) is used in order to get an idea, how the mask sitting on patient nose while inhaling sedative drugs. Scores from 1 to 4 is expressing results [10].
Modified observer assessment of alertness and sedation scale (MOASS) is giving us information about effectiveness and response to sedation. Scores ranges from 1 to 6 [18].
Table3. Description of the main behavior scales used to evaluate the success of sedation.
Researcher s
Scales used to evaluate sedation effectiveness
Description of scale/ score
Galeotti A e t a l . , 2 0 1 6 ; Ritwik et al2013; Singh C et al., 2014 H e a r t r a t e , o x y g e n saturation, and pulse rate.
Silay E et al., 2012 Haberland CM. et al., 2011
Houpt sedation rating scale
1 Aborted
2 Poor: Treatment interrupted, only partially completed
3 Fair: Treatment interrupted, but eventually all completed
4 Good: Difficult, but all treatments performed 5 Very good: Some limited crying or movement 6 Excellent: No crying or movement
Hitt JM. et al., 2014 A n t u n e s DE et al., 2016
Ohio State University behavior rating score
1. Quiet behavior, no movement 2 Crying, no struggling
3 Struggling movement without crying 4 Struggling movement with crying Haberland CM. et al., 2011 University of Michigan sedation scale(UMSS) 0 Awake/alert
1 Minimally sedated: tired/sleepy, appropriate response to verbal conversation and (calling child’s name)
2 Moderately sedated: somnolent/sleeping, easily aroused with light tactile stimulation (lightly touching arm ,face, or leg)
3 Deeply sedated: deep sleep arousable only with significant physical stimulation (tickling their feet)
4 Unarousable: unresponsive to foot tickle Done V et
al., 2016
F r a n k e l B e h a v i o r a l Rating Scale
Rating 1: Definitely negative: Child refuse treatment, cries forcefully, fearfully,
Rating 2: Negative: Reluctant to accept treatment and some evidence of negative attitude (not profound)
Rating 3: Positive: The child accepts treatment but may be cautious. The child is willing to comply with the dentist, but may have some reservations.
Rating 4: Definitely positive: This child has a good rapport with the dentist and is interested in the dental treatment.
Peerbhay F e t a l . , 2016, Galeotti A et al., 2016 Ve n h a m a n x i e t y / behavior scale 0 Total cooperation
1 Mild, soft verbal protest or (quiet) crying 2 Protest more prominent; both crying and hand signals
3 Protest presents real problem to dentist 4 Protest disrupts procedure
5 General protest, no compliance or cooperation Singh C et al., 2014 Behavior/response to t r e a t m e n t ( e a s e o f treatment completion) rating scale
5 Quiet and cooperative, no or slight cry and treatment completed without difficulty
4 Mild objections or whimpering but treatment not interrupted. Treatment completed without difficulty
3 Crying with minimal disruption to treatment. Treatment completed with minimal difficulty 2 Struggling that interfered with operative procedures. Only partial treatment completed with difficult
1 Active resistance and crying, treatment cannot be rendered
Bhat R et al., 2016
Mask acceptance scale (MAS)
1 Excellent (unafraid, cooperative, accepts mask readily)
2 Good (slight fear of mask, easily reassured) 3 Fair (moderate fear of mask, not calmed with reassurance)
4 Poor (terrified, crying, or combative). M a l h o t r a PU et al., 2016 M o d i f i e d o b s e r v e r assessment of alertness a n d s e d a t i o n s c a l e (MOASS)
1 Does not respond to mild prodding and shaking 2 Responds only mild prodding and shaking 3 Responds only after name is called loudly and repeatedly
4 Lethargic response to name spoken in normal tone
5 Appear asleep but respond readily to name spoken in normal tone
6 Appear alert and awake, response readily to name spoken in normal tone
3. Discussion
Variety of carried out studies, when different medications’ dosage, administration way and plenty of behavior scales to evaluate the success are applied, shows that one the most proper conscious sedation’s method does not exist. Nowadays, there is a trend of increasing cases of applied sedation worldwide. The most important advantages are the following minimizing psychological trauma, help to control behavior and movement and allowance to perform dental treatment for non-cooperative patients in pediatric dentistry. The use of sedative drugs alongside local anesthetics is often appropriate to reduce anxiety and fear among patients. This systematic review shows that sedation has not only beneficial outcome, but also side effect like hypersedation, respiratory disorder, headache, hyperexcitability, nausea, vomiting, crying and others as well. Consequently, these complications usually are short-term and resolve within 48 hours. Ritwik et al. was analyzing what the most common adverse effects after the discharge of the child are noticed within 8 or 24 hour after the procedure when different combination of medications were administered for sedation. Moreover, the same drug can be administered via different routes and varying clinical protocols that can be used to induce conscious or deep sedation. Some researchers agree, that intravenous administration of sedative and analgetic medications increases the likelihood of satisfactory sedation for both moderate and deep sedation [19]. Oral administration may be even more difficult in uncooperative children. Of the articles selected for this systematic review, midazolam was the most frequently used medication in comparison with other ones. Furthermore, combination of midazolam and hydroxyzine administered orally can prevent nausea and vomiting as well [20]. Dexmedetomidine, another effective sedation drug has a longer onset of action when compared with midazolam. Due to minor adverse effects of Dexmedetomidine drug, it makes it to another great option of usage. Intranasal sedation is easy and acceptable to achieve. (Singh et al. 2014, Bhat et al. 2016). Although success of sedation nitrous oxide is high by many performed studies worldwide, but this medication may pose a potential risk to clinical personnel who are providing sedation on regular basis.
Drug selection, dose and combination are three important factors to be considered for favorable results when conscious sedation is underway in order to control anxiety and negative behavior during dental procedures [19].
Success of sedation can be related to patient’s age and extent of performed dental procedures as well.
There is a variety of behavior assessment scales for pediatric dental sedation it is difficult to compare studies in a systematic review and then guide the clinician through the evidence revealed about this topic [21].
Usage of behavior scales permit to evaluated and compare the effectiveness of various sedative medications or their combinations how negative behavior of child can change. Scales that express children's behavior are an important factor in making decisions regarding behavioral management techniques in pediatric dentistry. One of the findings of this study is that the global scales (Houpt, and Venham) were highly correlated in their assessment of young children's behavior during dental sedation [9, 10]. But in some studies researches claim that noticed differences of results can be due to differences in type of behavior classification as well.
For example, the main advantage of the Houpt behavior rating scale is that it allows to evaluate sedation depth, the child’s behavior, and an overall rating of the visit, but one drawback is that the measure of success focuses primarily on the clinician’s ability to complete treatment [22]. A number of authors have suggested that outcome assessment should be more patient-focused [23].This recognizes that the intent of sedation is not only to complete a procedure with minimal movement and crying, but also that the child leaves with a positive impression of dental care [24].
Conclusion
To sum up, the most common drug used for achieving conscious sedation was midazolam (for mild sedation) mainly administered intranasal or orally, due to safe sedative action. While ketamine was also useful when administered intranasal, inducing a deep level of sedation and its combination with dexmedetomidine showed better effects of sedation. Hydroxyzine is also a very safe and effective sedative.
This systematic review showed that many different behavior scales were used to evaluate the improvement of patient behavior in carried out studies. Usually success of sedation was reported when patients permitted to accomplish dental procedures, whereas some studies were focused more on possible side effect after procedure.
However, further clinical studies need to be done in order to compare these drugs and get more evidence in knowing, which of these has the best safety and effectiveness peculiarities.
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