Please click on the tables and figures to enlarge
A synopsis of articles of interest from the last twelve months to inspire further reading
The use of oral benzodiazepines for the management of dental anxiety: a web-based survey of UK dentists
Finn K, Moore D, Dailey Y and Thompson W
Br Dent J May 24 2023 https://doi.org/10.1038/s41415-023-5850-5
Abstract
Background
Oral benzodiazepines (OBZs) can facilitate treatment of dentally anxious patients and are widely used in countries such as Australia and the United States. Dentists in the UK prescribe them much less often.
Aims
To examine OBZ prescribing by dentists in the UK, including patterns of practice, barriers to use and alternative anxiety management strategies.
Methods
An online mixed methods survey was conducted utilising Qualtrics. Participants were recruited via the private Facebook group ‘For Dentists, By Dentists’ during April to June 2021. Quantitative data were analysed with descriptive statistics and qualitative data with thematic analysis.
Results
In total, 235 dentists participated, with 91% being general dentists. Half had previously prescribed OBZs, with 36% doing so in the last year. Only 18% were confident in their use. Diazepam was the anxiolytic preferred by respondents.
Two-thirds of dentists who had never prescribed anxiolytics were interested in doing so in the future. Concerns about managing anxious patients with OBZs included: inadequate training; confusion about guidelines; medico-legal risk and issues of general practitioners prescribing anxiolytics to dental patients unbeknown to their dentist.
Conclusions
A lack of confidence prescribing OBZs for anxiolysis exists among UK dentists. Guidelines should be clarified, and training provided.
Reviewer’s evaluation, opinion and points of interest
Any medication or technique which reduces anxiety is to be welcomed but it is evident that many practitioners, especially those in the UK, are not benefiting from the efficacy of OBZs by prescribing them for their dentophobic patients when clinically necessary.
The paper is based on a survey which studied prescribing patterns and found that there was a general lack of confidence about providing OBZs despite it being accepted that patients who have taken anxiolytics are generally reported to have a positive experience and are relatively easier to treat.
One of the reasons cited is changes in the legal framework for controlled drugs and, surprisingly, the introduction of the IACSD sedation guidelines, which in making sedation protocols more robust seemed to have caused confusion for some practitioners, including whether additional qualifications are required for prescribing anxiolytic pre-medication.
For example, the authors inform that the British National Formulary recommends temazepam, a Schedule 4 controlled drug (CD), as more suitable because of its reduced half-life compared to diazepam, a Schedule 3 CD. However, the Scottish Dental Clinical Effectiveness Programme (SDCEP) drug prescribing guidelines recommend only diazepam as pre-medication. These sorts of discrepancies between the two documents are examples of the lack of clear guidance for dentists regarding OBZ prescribing.
The study also demonstrated that some GPs have been playing a role in the management of dentally anxious patients by prescribing OBZs both with, and without, the involvement of their patient’s dentist. Besides placing an increasing burden on GPs, this could pose a significant medico-legal risk for dentists treating patients without knowledge that they had taken OBZs.
In this regard, it is suggested that:
- dentists should be allowed access to central records to view a patient’s relevant medical history, especially details of any medication being taken
- and that strategies to safely manage dentally anxious patients across primary care settings and improve liaison between GPs and dentists should be developed.
Interestingly, the study found that younger dentists were less likely to have prescribed OBZs which suggests that dental schools may need to boost their teaching about the pharmacological management of anxious dental patients with OBZs as pre- medication.
The authors do not recommend widespread use of OBZs and instead advocate the need for the establishment of clear national guidelines on safe OBZ prescribing.
FA
Let’s be more conscious about the misuse of nitrous oxide
R S Bird
Br Dent J 2023;234:652-653
Abstract
Following the ‘No laughing matter’ article published in 2020 by Dr Croser, this paper further highlights the increasingly concerning problem of the illicit use of nitrous oxide. Since 1884, the benefits of nitrous oxide have been exploited in the field of dentistry. Its analgesic and mild anaesthetic properties, alongside suggestive hypnosis and reassurance are often enough to relieve the anxieties of our patients sufficiently to enable dental treatment. When used appropriately, it has a wide margin of safety and no significant side effects. However, the instantaneous feeling of euphoria experienced after inhaling the drug lends itself to recreational use. This is becoming more popular among the younger generations of the population; the drug is both incredibly easy and cheap to purchase, at only 22p a cannister. More than half a million teenagers and young adults are using this drug at present. Grieving parents of teenagers who have tragically lost their lives to this drug are pleading for people to stop and for The Advisory Council on the Misuse of Drugs to criminalise nitrous oxide.
Let’s be more aware of the dangers of nitrous oxide, encourage those to seek help when they need it and refer to local drug support services; it could help to save lives.
Reviewer’s evaluation, opinion and points of interest
This short paper was originally published in May 2023 and was one of many calls to criminalise the increasing use of nitrous oxide for recreational purposes in recent years. Those appeals were eventually heeded by the updating of the law to make possession of nitrous oxide illegal from 8 November 2023 if it was, or was likely to be, ‘wrongfully inhaled’ by classifying it as a Class C drug under the Misuse of Drugs Act 1971.
The author states that a total of 716 deaths related to volatile substances were recorded in England and Wales between 2001 and 2020. Of these, 56 cases were related to the illicit use of nitrous oxide. These figures clearly indicate that although nitrous oxide is used widely in dental and medical fields for its anxiolytic and analgesic properties, it has nevertheless to be administered with care and can be dangerous, indeed fatal if misused.
The paper explains that the instantaneous feeling of euphoria experienced after inhaling the drug lent itself to recreational use and that this ‘high’ was being chased by many more people across the UK than previously seen. The author asks, ‘with this drug being so accessible, is it any wonder that more than 500,000 of our 16 to 24- year-olds are using it?’
The author must be credited for contributing towards the campaign for the banning of nitrous oxide in the UK. The implementation of the ban is in its early stages and it may take time not only to curb demand, but also to close off the sources. Therefore, it remains necessary to maintain the process of educating the public on the harsh realities of misusing nitrous oxide. Indeed, healthcare professionals can find it easier to access nitrous oxide in their place of work, so the paper makes an important point for the need to guide and support our colleagues as well.
FA
Oral midazolam vs. intranasal dexmedetomidine nplus oral midazolam for sedation of pediatricnoutpatients: a double-blinded randomizedncontrolled trial.
Nie J, Chen C, Xie J, Ding G
BMC Anesthesiology. 2023; 2: 341-350
Abstract
Background
Moderate to deep sedation is required for dental treatment of children with dental anxiety. Midazolam is the most commonly used sedative, whereas intranasal dexmedetomidine is increasingly used in pediatric sedation.
Objective
The aim of this trial was to compare the sedative efficacy of oral midazolam alone with that of intranasal dexmedetomidine plus oral midazolam during dental treatment of children with dental anxiety.
Design
In total, 83 children (aged 3 to 12 years) scheduled to undergo dental sedation were randomized to receive oral midazolam (0.5 mg/kg) and intranasal placebo, or oral midazolam (0.5 mg/kg) plus intranasal dexmedetomidine (2 microg/kg). The primary outcome was the rate of successful sedation for dental treatment. Secondary outcomes were the onset time and adverse events during and after treatment. Data analyses involved descriptive statistics and nonparametric tests.
Results
The rate of successful sedation was significantly higher in combination group (P = 0.007), although the sedation onset time was significantly longer in combination group (17.5 + / - 2.4 min) than in monotherapy group (15.7 + / - 1.8) (P = 0.003). No children required medical intervention or oxygen therapy for hemodynamic disturbances, and the incidences of adverse events had no significant difference between groups (P = 0.660).
Conclusion
Combined treatment with oral midazolam (0.5 mg/kg) and intranasal dexmedetomidine (2 microg/kg) is more significantly effective for managing the behavior of non-cooperative children during dental treatment, compared to oral midazolam (0.5 mg/kg) alone. (Chinese Clinical Trial Registry: ChiCTR2100042300) TRIAL REGISTRATION: ChiCTR2100042300, Clinical trial first registration date: 17/01/2021.
Reviewer’s evaluation, opinion and points of interest
It is rare to find randomised controlled trials in paediatric sedation. The success rate for oral midazolam is lower than many of us would expect, however, the article is adding to a body of evidence that dexmedetomidine may be a drug that is of use in the clinical practice of sedation.
I am slightly suspicious of the value of articles where the experimental sedation technique is the control plus an additional agent. I am concerned that, if the control technique is one proven to produce the desired level of sedation, will the addition of a second drug be likely to produce oversedation? Indeed, in the discussion the authors refer to the technique as being ‘more favorable for children with severe dental anxiety, needing deep sedation for treatment.’ The Ramsay Sedation Score as quoted in this paper is different to the version I am used to where the score of five would be categorised as ‘asleep’ and thus potentially beyond the UK definition of sedation.
Reading any article from countries where the definition of sedation is different from your own means that the article must be approached with a critical appraisal lens rather than accepting the printed word as gospel.
NR
Perioperative management of oral antithrombotics in dentistry and oral surgery: Part 2. [Review]
Statman B J
Anesthesia Progress. 70:37-48, 2023 03 01
Abstract
Part 1 of ‘Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery’ covered the physiological process of hemostasis and the pharmacology of both traditional and novel oral antiplatelets and anticoagulants. Part 2 of this review discusses various factors that are considered when developing a perioperative management plan for patients on oral antithrombotic therapy in consultation with dental professionals and managing physicians. Additionally included are how thrombotic and thromboembolic risks are assessed as well as how patient and procedure-specific bleeding risks are evaluated. Special attention is given to the bleeding risks associated with procedures encountered when providing sedation and general anesthesia within the office-based dental environment.
Reviewer’s evaluation, opinion and points of interest
This article makes interesting reading for those who provide surgical treatment for medically compromised patients. Much has been written regarding how the need to modify patients' medication has been reduced given the introduction of newer antithrombotic drugs. This article concentrates on the clinical relevance of the drugs with particular reference to general anaesthesia and sedation practice. There is an earlier article from the authors which concentrates more on the pharmacology of the agents.
I would recommend this article for those who are performing procedures with a significant risk of bleeding on the ever- increasing number of patients taking these medications.
NR
Comparison of oropharyngeal oxygen pooling and suctioning during intubated and nonintubated dental office-based anesthesia.
Rafla R R, Saxen M A, Yepes J F, Jones J E, Vinson L A
Anesthesia Progress. 2023; 70: 3-8
Abstract
Objective
The risk of a spontaneous surgical fire increases as oxygen concentrations surrounding the surgical site rise above the normal atmospheric level of 21%. Previously published in vitro findings imply this phenomenon (termed oxygen pooling) occurs during dental procedures under sedation and general anesthesia; however, it has not been clinically documented.
Methods
Thirty-one children classified as American Society of Anesthesiologists I and II between 2 and 6 years of age undergoing office-based general anesthesia for complete dental rehabilitation were monitored for intraoral ambient oxygen concentration, end-tidal CO2, and respiratory rate changes immediately following nasotracheal intubation or insertion of nasopharyngeal airways, followed by high-speed suctioning of the oral cavity during simulated dental treatment.
Results
Mean ambient intraoral oxygen concentrations ranging from 46.9% to 72.1%, levels consistent with oxygen pooling, occurred in the nasopharyngeal airway group prior to the introduction of high-speed oral suctioning. However, 1 minute of suctioning reversed the oxygen pooling to 31.2%. Oropharyngeal ambient oxygen concentrations in patients with uncuffed endotracheal tubes ranged from 24.1% to 26.6% prior to high-speed suctioning, which reversed the pooling to 21.1% after 1 minute.
Conclusion
This study demonstrated significant oxygen pooling with nasopharyngeal airway use before and after high-speed suctioning. Uncuffed endotracheal intubation showed minimal pooling, which was reversed to room air ambient oxygen concentrations after 1 minute of suctioning.
Reviewer’s evaluation, opinion and points of interest
Although the use of General Anaesthesia (GA) for dentistry was supposed to be declining, there is some evidence that the lockdowns and restrictions on the provision of routine treatment have increased the waiting lists for treatment. When this reviewer was studying dentistry, it was common for GA to be administered without the use of endotracheal tubes (ETT) (the Laryngeal Mask Airway (LMA) was yet to be invented). It would appear that the routine use of either ETTs of LMAs has become more prevalent, although both have disadvantages in terms of the facility to carry out dental treatment and postoperative complications. This paper provides a different angle on the pros and cons of different airway management techniques under GA, particularly where there is a risk of spark generation.
NR
The value of bitewing radiographs in the management of carious primary molars - the impact on treatment planning
A. Anwar, A J Keightley and Elizabeth M Roebuck
Br Dent J 2023; Nov 17. https://doi.org/10.1038/s41415-023-6496-z
Abstract
Introduction
Bitewing radiographs (BWs) with visual examination (VE) are critical for the early detection of caries in primary molars. However, their influence on treatment planning is not extensively studied. Given they involve exposure to ionising radiation, it is essential to understand their impact on treatment decisions.
Aim
To explore the impact of BWs in the management of carious primary molars.
Design
Cross-sectional study.
Materials and methods
A total of 30 children (mean age 6.2 years) referred for caries management in a dental hospital setting were recruited. One of six paediatric dental specialists performed VEs and scored pre-BW treatment needs (TN) for each primary molar, followed by reviewing the BWs, re-scoring TN and recording their opinion on treatment modality. Data were assessed using descriptive analyses.
Five treatment planning descriptors detailing the reasons for change were identified.
Results
In total, 240 primary molars were examined. BWs resulted in an overall change in treatment plan for 24/30 (80.0%) children, with the majority (20/30; 66.7%) becoming more invasive. General anaesthesia was the commonest proposed modality (13/30; 43.3%) children), followed by inhalation sedation (10/30; 33.3%) and local anaesthesia (6/30; 20.0%), with only one child (3.3%) in the ‘o analgesia’ modality.
Conclusion
BWs play an important role in treatment planning carious primary molars.
Reviewer’s evaluation, opinion and points of interest
This is a really interesting 'real world' paper which demonstrates how taking bitewing radiographs influences treatment planning for carious primary molars in a secondary care referral service. The authors have done a great job of presenting their complex data with simple and easy to understand infographics. It is notable that bitewings changed the treatment plan in 80% of the cases in this series, with two thirds of those changing to a more invasive treatment plan. In the discussion the authors consider the complexity of decision making in these cases and in particular how the choice of GA tends to increase the number of pragmatic extractions to reduce the risk of repeat general anaesthesia. This article provides good evidence to support not only the guidelines recommending routine bitewings, but to demonstrate that in daily clinical practice these radiographs provide additional, useful clinical information that helps treatment planning.
GG
Feasibility of minimum intervention oral healthcare delivery for individuals with dental phobia
Heirdari E, Banerjee A and Newton, J T.
BMC Oral Health 2023;23:531
Abstract
Background
People with dental phobia often present with more active dental caries and fewer teeth. Minimum intervention oral healthcare (MIOC) offers a possible solution to address the high care needs of this group. The aim was to determine this patient group’s eligibility and willingness to participate and the effect of MIOC, compared to treatment as usual (TAU), on their oral health outcomes for planning a future randomised controlled trial (RCT).
Minimum intervention oral healthcare comprises four interlinked domains. In the first domain, we identified and diagnosed the disease status and participants’ anxiety status (≥19 MDAS). In the second domain, an individualised prevention based personalised care plan was designed. During this process, patients with dental phobia were exposed to the dental environment in a stepped manner (‘graded exposure’) and had their urgent care provided with conscious sedation. In the third domain, we took a minimally invasive operative approach to restore teeth while preserving tooth substance and limiting the use of fear-provoking stimuli (eg rotary instruments) when possible. At the review and the recall appointment(s) (fourth domain) the patients’ oral health care behaviours, disease risk / susceptibility and fear levels were re-assessed.
Methods
This two-arm randomised feasibility trial (N = 44) allocated participants to the experimental arm (MIOC) or the control arm (TAU). The primary outcomes were the eligibility and willingness to participate and feasibility to conduct a trial of MIOC for people with dental phobia. The secondary outcomes were oral health status, oral health related quality of life and care completion. Written and verbal consent for participation and dental care provision were obtained.
Results
Forty-four people diagnosed with dental phobia were allocated randomly to the two study arms. At the six-month recall after completed care the outcome of each study arm was assessed. It was feasible to conduct a clinical trial (eligibility rate: 56%, completion rate: 81%, declined to participate: 12%). The intervention group showed improvements in all health care outcomes and oral health related quality of life.
Conclusion
A clinical trial of MIOC vs TAU in people with dental phobia is feasible. Preliminary findings suggest that patients in the MIOC arm are more likely to successfully complete their course of treatment. The study was ‘retrospectively registered’ on 02/05/2018 (ISRCT15294714) with the International Standard Randomised Controlled Trial (ISRCT).
Reviewer’s evaluation, opinion and points of interest
This recently published paper highlights how the ‘minimum intervention oral healthcare’ (MIOC) approach to patient care provides a helpful framework to support patient care for adults with dental anxiety and phobia. This feasibility study was conducted in order to establish the parameters of a future randomised controlled trial (RCT), as well as to explore participant’s views and the impact of MIOC on oral health outcomes and oral health-related quality of life (OHRQoL).
The paper describes the four domains of MIOC in detail:
- assessment and identification of the patient’s problems (in terms of detection, risk and susceptibility to oral diseases)
- prevention via primary, secondary and tertiary prevention of lesions and control of dental disease with an individualised programme
- minimally invasive operative management and treatment of oral health disease (with reported limited use of dental drills, and selective removal of carious tissue in active lesions)
- recall and review of provided treatment and oral health related behaviours, to reassess oral disease susceptibility.
Conducted in a secondary care sedation and special care department, participants were identified who met the inclusion criteria and then randomly allocated to either the described MIOC pathway, or treatment as usual (TAU) which was with conscious sedation where appropriate. The MIOC pathway also included treatment with behaviour management and conscious sedation where necessary / appropriate. A detailed events matrix is included in the paper explaining the process and patient engagement processes from start to finish.
The results describe support of providing MIOC within the setting with good attendance rates and low attrition for the intervention group overall. Interestingly, the participants within the intervention arm presented with ‘…better OHR behaviours than the general UK phobic population’, which improved further after the intervention. However, comparisons are hard to draw with the TAU group due to the high dropout rate at follow up, with only 2 out of the 22 allocated to TAU. The person-centred approach to care MIOC offers was proposed to explain some of the difference in follow up rates. It would have been interesting to examine the impact on dental anxiety with a post-MDAS comparison, however, the authors report high satisfaction rates and expressed improved OHR QoL, which is in itself encouraging and supports their findings for the feasibility of employing MIOC among this patient group.
JH
Managing dental phobia in children with the use of virtual reality: a systematic review of the current literature
Rosa A, Pujia A M, Docimo R. and Arcuri
C. Children 2023;10:1763.
Abstract
Background
It is common today to encounter anxiety in patients facing dental treatment. Virtual reality (VR) is presented as a high performing and innovative procedure because it can distract patients undergoing dental procedures or prepare them for such treatments. In addition, this meta-analysis has gathered evidence on VR and its ability to reduce dental anxiety in paediatric patients undergoing different treatments.
Methods
The major Scopus, PubMed, EMBASE and Web of Science databases were searched for scientific articles published up to 2023. Studies in which VR were used for children and adults as a measure against anxiety during dental treatments were included. VR was defined as a three-dimensional place where patients experience a sense of immersion as they find themselves in attractive and interactive environments that detach them from reality. Anxiety and pain were examined and measured during dental treatments in which VR was used by comparing them with standard care situations.
Results
Twenty-five studies were identified, of which eleven met the inclusion criteria. The effect of VR was studied mainly in the paediatric population as a distractive method. Only two studies (not significant) on an adult population were considered.
Conclusions
This review shows that VR is an excellent distraction method that is effective in reducing anxiety before dental treatment. However, due to the few studies in this area, further research on VR as a tool to prepare patients for dental treatment is needed.
Reviewer’s evaluation, opinion and points of interest
This systematic review and meta-analysis rigorously searched available literature to explore the use of virtual reality (VR) among children to manage dental phobia when applied as a therapeutic intervention. Eleven studies were selected that met the inclusion criteria, which included interventions applied among ≤18-years-of age (which might also include adults), a mean score for pain or anxiety during the procedure and a measure of distraction for both the intervention and control groups. The results are interesting, as they explore both ratings for anxiety and pain. In this study the authors found that participants who used VR reported a lower sense of pain during the dental procedure compared to control groups not using VR. This was statistically significant in a meta- analysis performed in a random-effect-model.
The authors discuss the findings and implications, though it would have been of interest to include more detail and clarity about the interventions included and how VR was being used, which was typically by way of distraction. More information on the control interventions would have also been valuable, though the authors noted the paucity of detail for this in the published papers. Nonetheless, the paper points to the importance of VR immersion as a phenomenon that needs further research to more fully understand its utility as a distractive intervention, and what makes it superior to 2D non-immersive distraction techniques.
JH
The CALM trial protocol: a randomised controlled trial of a guided self-help cognitive behavioural therapy intervention to reduce dental anxiety in children
Marshman Z, Rodd H, Fairhurst C, Porritt J, Dawett B, Day P, Innes N, Vernazza C, Newton T, Ronaldson S, Cross L, Ross J, Baker SR, Hewitt C, Torgerson D, Ainsworth H.
Trials – 24 (1): 15, Published online: January 2023
Abstract
Background
Globally around 13% of children experience dental anxiety (DA). This group of patients frequently miss dental appointments, have greater reliance on treatment under general anaesthesia (GA) and have poorer oral health-related quality of life (OHRQoL) than their non-dentally anxious peers. Recently a low-intensity cognitive behavioural therapy (CBT) based, self-help approach has been recommended for the management of childhood anxiety disorders. A feasibility study conducted in secondary care found this guided self-help CBT resource reduced DA and a randomised controlled trial was recommended. The present study aims to establish the clinical and cost-effectiveness of a guided self-help CBT intervention to reduce DA in children attending primary dental care sites compared to usual care.
Methods
This 4-year randomised controlled trial will involve 600 children (aged 9 to 16 years) and their parent/carers in 30 UK primary dental care sites. At least two dental professionals will participate in each site. They will be assigned, using random allocation, to receive the CBT training and deliver the intervention or to deliver usual care. Children with DA attending these sites and in need of treatment will be randomly allocated to be treated either by the intervention (CBT) or control (usual care) dental professional. Children will complete questionnaires relating to DA, OHRQoL and health-related quality of life (HRQoL) before treatment, immediately after treatment completion and 12 months post- randomisation. Attendance, need for sedation/GA and costs of the two different approaches will be compared. The primary outcome, DA, will be measured using the Modified Child Dental Anxiety Scale. Scores will be compared between groups using a linear mixed model.
Discussion
Treating dentally anxious patients can be challenging and costly. Consequently, these children are frequently referred to specialist services for pharmacological interventions. Longer waiting times and greater travel distances may then compound existing healthcare inequalities. This research will investigate whether the intervention has the potential to reduce DA and improve oral health outcomes in children over their life course, as well as upskilling primary dental healthcare professionals to better manage this patient group.
Reviewer’s evaluation, opinion and points of interest
This protocol for a planned randomised controlled trial over a four- year period in the UK is an exciting one. It aims to establish the clinical and cost-effectiveness of a guided self-help Cognitive Behavioural Therapy (CBT) based intervention to reduce dental anxiety among children attending a dentist in primary care, compared to care as usual. The trial paper outlines all the intended study objectives, which also include trial feasibility, dental staff and participant engagement, the impact of the intervention with a 12-month follow-up period, a cost-effectiveness understanding and a process evaluation. The study is proposed to take place across 30 primary care dental sites, including GDPs and primary dental community clinics across some of the most deprived areas in the UK, with higher than average caries rates. The areas proposed for inclusion are the East Midlands, South Yorkshire, West Yorkshire, North East and Wales in order to increase diversity within socio-economic status and multi-ethnic representation to increase finding generalisability.
Eligibility criteria for participation include children aged between 9 and 16-years-old, without urgent treatment need and with self- reported child dental anxiety. The control group will receive care as usual which describes routine care supported by behavioural management alone (specifically: tell-show-do, reinforcement, modelling, distraction, voice control and enhanced control). The intervention will be the guided self-help CBT intervention: Your teeth, you are in control (available in English and Welsh), which will be available online and on paper, with an accompanying parental resource and delivered by a trained dental professional. The training for the dental professional will include a two-hour bespoke online format and a delivery guide with plans to monitor intervention fidelity throughout the study.
The trial paper provides a detailed plan for recruitment, allocation and blinding, as well as the statistical analysis, sample size, measures and outcomes which will include a helpful examination on parent dental anxiety levels, using the modified dental anxiety scale (MDAS).
The findings for this study will be four years in the making, though the guided self-help book Your teeth, you are in control has already been demonstrated to reduce anxiety in secondary care in a prior feasibility study and is available for purchase.
The collaboration led by the University of Sheffield has already made the resource available in a number of languages, along with a series of free training videos. To learn more about the intervention and the resources go to https://www.sheffield.ac.uk/dentalschool/research/person-centred-population/child-dental-anxiety/resources (accessed 14/1/23)
We wait for more information and I look forward to sharing the findings in another journal scan, four years or so from now. Best of luck to the research team in the quest to improve dental care and the experience of anxious children and parents in primary care.
JH
Clinical evaluation of feasibility and effectiveness using a virtual reality device during local anesthesia and extractions in pediatric patients
Pathak P D, Lakade L S, Patil K V, Shah P P, Patel, A R and Davalbhakta R N
Eur Arch Paediatr Dent. 2023;24:379-386
Abstract
Purpose
Pediatric dentistry requires more than routine dental knowledge and skills in executing quality dental care. The quality of dental treatment is indirectly proportional to a child's anxiety and fear. The recent distraction technique, the use of virtual reality (VR) devices, has intrigued many researchers’ minds. Therefore, this study was conducted to assess the clinical feasibility and effectiveness of the VR device in reducing pain and anxiety in pediatric patients during mandibular primary molar extraction.
Methods
This research trial had 30 healthy children between the ages of 6 and 12 who required mandibular primary molar extraction. The subjects were divided into two groups using a simple randomization method. In the study group (n = 15), extraction was carried out using a VR device, whereas, in the control group (n = 15), extraction was carried out without the use of a VR device. Pre- and post-extraction anxiety levels were measured by Venham's picture test (VPT) and the heart rate. After the procedure, pain and behavior were evaluated by the Wong-Bakers Faces pain rating scale (WBS) and FLACC Scale respectively.
Results
The pre-extraction values of the VPT and heart rate showed no statistically significant difference. This indicates that participants of both groups had a similar level of anxiety at baseline. There was a statistically significant increase (p = 0.028) between pre- and post- heart rates in the control group, with no significant change in the study group.
Conclusion
The use of a virtual reality device in children can reduce anxiety during primary molar extractions as evaluated by heart rate. Virtual reality devices might be an adjunct to high quality dental care and to other behavior management methods. Definitive outcomes can be attained by encouraging studies overcoming the present limitations and considering salivary biochemical indicators for the assessment of these devices.
Reviewer’s evaluation, opinion and points of interest
I was interested in this study where children wore virtual reality headsets to watch their favourite cartoons during primary molar extractions. They used the VR Shinecon device which has inbuilt headphones.
Whilst not reported in the abstract, they found a difference in success depending on the age of the child. They observed that the age group from 8 to 12 years adored the use of the virtual reality headset whereas the younger age group 6 to 8 showed less co- operation to wear it.
In this study, for the younger children, the headset used was described as hefty and the headphones did not fit as well. This made it harder to muffle out unwanted noise.
The dental operators also commented that it was difficult to support the child’s head or jaws during the extraction from the right-side quadrant because of the bulkiness of the device. The presence of the device led to difficulty in assessing the facial expression component of the FLACC (Face, Legs, Activity, Cry, Consolability) scale, the behavioural scale validated for assessing post-operative pain.
RW
Comparative study of two different computer controlled local anesthesia injection systems in children: a randomized clinical trial
Abou Chedid J C, Salameh M, El Hindy C, Kaloustian M K and El Hachem C
Eur Arch Paed Dent 2023;24:417-423 https://doi.org/10.1007/s40368-023-00793-3
Abstract
Purpose
To compare pain perception associated with two computer- controlled local anesthesia devices, the WAND™ STA (Milestone Scientific Inc., Livingston, NJ, USA) and the Calaject (Rønvig Dental MFG, Daugaard, Denmark) in young children.
Methods
A split-mouth randomized clinical trial comprising 30 patients, aged 6–12 years, received randomly, in two separate sessions, a local anesthesia injection in the maxilla using either the wand STA or the Calaject. Pain perception was evaluated using the patient’s heart rate, an 11-point numerical scale (NRS), and the Sound, Eye, and Motor (SEM) body movements. Statistical difference was set at p = 0.05. Repeated measures analysis of variance were conducted to compare the mean pulse for Calaject and STA at different times. It was followed by univariate analysis and Bonferroni multiple comparisons tests. Wilcoxon tests were performed to compare NRS, SEM, and injection duration between Calaject and STA.
Results
There was no significant statistical difference between Calaject and STA in pulse rate before injection (p = 0.720), during injection (p = 0.767), and after injection (p = 0.757). The mean NRS score was significantly greater with STA in comparison with Calaject (p = 0.017). The mean SEM score was also significantly greater with STA in comparison with Calaject (p = 0.002). However, the mean duration was significantly longer with Calaject (p = 0.001).
Conclusions
Calaject was more elective than STA in reducing pain perception associated with periapical injection in young children.
Reviewer’s evaluation, opinion and points of interest
Fear of dental anaesthetic is one of the major barriers to attending the dentist. Therefore, it is particularly important that children having their first experience of dentistry do not have an upsetting one. Moreover, a negative treatment experience can alter the patient’s pain perception and lower its threshold.
I was interested in this study as I have been using the WAND™ STA with paediatric patients since its inception but have no experience of the Calaject system. Computer-controlled delivery systems aim to reduce the discomfort produced by local anaesthetic injection. They allow the delivery of local anaesthetic solution at a fixed pressure-to-volume ratio regardless of variations in tissue resistance. They are able to start the injection at a pressure below 306mmHg, a precision not able to be attained manually and dependent greatly on the dexterity of the dentist and their experience.
The Calaject has been relatively recently introduced and comprises a mobile unit with a built-in pressure indicator and a three button display to choose between three programmes. The unit is adapted to a pen shaped container where the cartridge and needles that serve as a syringe are placed. It is compatible with all anaesthetic needles and cartridges from all brands.
The objective of this study was to compare the two computer- controlled devices adopting a split mouth design with each child as their own control. This is the first study to do this comparison to my knowledge. The injections were performed on two separate occasions to overcome the possibility of an uncomfortable stimulus during the first session interfering with pain perception and anxiety during the second one.
The authors acknowledge that the perception of pain is difficult to evaluate scientifically, since it is affected by the emotional and developmental stage of the child, fear, anxiety and past experiences. In this study they used a pulse oximeter to record the patient’s heart rate at rest, during the injection and during the treatment. Patients were asked to rate the level of pain perceived during the administration using an 11-point numeric scale (NRS). The sound, eye and motor reactions (SEM) were observed throughout the procedure by the dental nurse. For both scales there were significant differences between the two systems indicating less discomfort and distress with the Calaject device. It must be remembered that both systems have been shown in other studies to be preferred by patients compared with the traditional technique.
The authors reported no financial or non-financial interests to disclose and no conflicts of interest. More studies are needed to confirm the superiority of one system over the other. It will be interesting to observe if the introduction of another computer- controlled delivery system will increase their uptake by dentists in practice.
RW
Development of a pharmacokinetic and pharmacodynamic model for intranasal administration of midazolam in older adults: a single-site two-period crossover study
Barends C, Daa, I, Driesens M, Visser A, Absalom A, Colin P. Br. J.
Anaesth. 2023; 131:284-293
Abstract
Background
Intranasal midazolam can produce procedural sedation in frail older patients with dementia who are unable to tolerate necessary medical or dental procedures during domiciliary medical care. Little is known about the pharmacokinetics and pharmacodynamics of intranasal midazolam in older (>65-year-old) people. The aim of this study was to understand the pharmacokinetic / pharmaco- dynamic properties of intranasal midazolam in older people with the primary goal of developing a pharmacokinetic / pharmaco- dynamic model to facilitate safer domiciliary sedation care.
Methods
We recruited 12 volunteers: ASA physical status 1 to 2, aged 65 to 80 years old and received midazolam 5 mg intravenously and 5 mg intranasally on two study days separated by a 6-day washout period. Concentrations of venous midazolam and 1ʹ-OH- midazolam, Modified Observer’s Assessment of Alertness / Sedation (MOAA/S) score, bispectral index (BIS), arterial pressure, ECG, and respiratory parameters were measured for 10 h.
Results
Time to peak effect of intranasal midazolam for BIS, MAP, and SpO2 were 31.9 (6.2), 41.0 (7.6), and 23.1 (3.0) min, respectively. Intranasal bioavailability was lower compared with intravenous administration (Fabs 95%; 95% confidence interval: 89-100%). A three-compartment model best described midazolam pharmacokinetics following intranasal administration. A separate effect compartment linked to the dose compartment best described an observed time-varying drug-effect difference between intranasal and intravenous midazolam, suggesting direct nose-to-brain transport.
Conclusions
Intranasal bioavailability was high and sedation onset was rapid, with maximum sedative effects after 32 min. We developed a pharmacokinetic / pharmacodynamic model for intranasal midazolam for older persons and an online tool to simulate changes in MOAA/S, BIS, MAP and SpO2 after single and additional intranasal boluses.
Reviewer’s evaluation, opinion and points of interest
Research has shown that intranasal midazolam administration produces adequate sedation with a predictable onset time and plasma concentration profile in both children and younger adults. Although older people are generally considered more susceptible to benzodiazepines, there is little published information about the pharmacokinetics and pharmacodynamics of intranasal midazolam in older people over the age of 65.
Based on their findings, the authors propose that midazolam is likely to reach the central nervous system by direct nose-to-brain transport in addition to the vascular system, with several physiological mechanisms of direct nose-to-brain transport described. This includes diffusion into perineural spaces, crossing the cribriform plate to enter the cerebrospinal fluid and intracellular transport through olfactory sensory neurones.
Aside from the interesting data set presented in this study, I would like to draw the attention of readers to the online tool constructed by the authors to simulate changes in physiological measures after varied amounts of initial loading dose and additional intranasal boluses of midazolam. This was developed under the Department of Anaesthesiology, University Medical Center Groningen, and is freely accessible by following the link: https://umcgresearch.org/w/anaesthesiology (accessed 10/11/23).
The simulations suggested that a single 5 mg bolus of midazolam administered intranasally (2.5 mg in each nostril) in healthy older persons is likely to lead to clinical sedation after ~30 minutes with little cardiorespiratory compromise. The authors acknowledge, however, that this tool is based on healthy older people, therefore further research on administration of midazolam in older people with poor health or dementia is needed. In addition, the sample size was small therefore a wider data set is desirable. Such work is important as the population of older people is rapidly increasing and presents a significant challenge to our services in the future.
I recommend that readers explore this publication and online tool considering whether such applications will become a more frequent way of informing our sedation risk assessments and delivery of treatment in the future, as technology plays an ever- increasing role in healthcare.
SC
Conscious sedation for dental treatments in subjects with intellectual disability: a systematic review and meta-analysis
Salerno C, Cirio S, Zambon, G, D’Avola V, Parcianello R G, Maspero C, Campus G, Cagetti M G.
Int. J. Environ. Res. Public Health 2023; 20: 1779.
Abstract
This systematic review and meta-analysis aimed to investigate the conscious sedation efficiency in patients with intellectual disability undergoing dental treatment (PROSPERO CRD42022344292). Four scientific databases were searched by ad hoc prepared strings. The literature search yielded 731 papers. 426 were selected, 42 were obtained in full text format and 4 more were added after hand searching. Fourteen studies were finally included, 11 of which were included in the meta-analysis (random effect model). A high heterogeneity in the drugs used and route of administration was retrieved. Success rate, occurrence of side effects and deep sedation occurrence were combined to give an overall efficiency of each drug. N2O/O2 reported the highest efficiency (effect size = 0.90; p <0.01) and proved to be more efficient when used alone. Nine papers reported a success rate of sedation of 80% or more. The prevalence of side effects (6 studies) ranged from 3% to 40%. Enteral and parenteral benzodiazepines showed the same overall efficiency (effect size = 0.86). No meta-analysis has yet been conducted to define the most effective and safest way to achieve conscious sedation in patients with intellectual disability; nitrous oxide appears to be the best choice to perform conscious sedation in patients with intellectual disability undergoing dental treatment.
Reviewer’s evaluation, opinion and points of interest
I enjoyed reading this publication, as it provided an excellent overview of the common challenges faced in the provision of dental care for patients with intellectual disabilities across age ranges. The majority of the research conducted on subjects with disability focuses on the use of general anaesthesia (GA) although there is a growing body of evidence of the use of sedation in this group, therefore this review is of particular interest to members of the readership working in paediatric and special care dentistry.
The authors provided a comprehensive description of the methodology for this systematic review, highlighting that a review of this kind was not without challenges. In particular, the search was limited to English, Italian and French languages. I also note that efforts were made to capture publications through a variety of search terms. However, the language used to define sedation in different settings and the severity of disability in this patient group has changed significantly over the last 40 years across the world, which creates difficulties when identifying relevant publications and sifting through the literature.
In their conclusion, the authors suggest that nitrous oxide appears to be the most appropriate choice to perform conscious sedation in individuals with intellectual disability undergoing dental treatment. However, for many of us working with patients with severe intellectual disabilities often confounded by behaviour that challenges the delivery of care in clinical settings, this would not be considered a suitable modality. The authors explain that there is great heterogeneity in the included studies, their design and the risk of bias. This therefore highlights the need for more well- designed research in this important area. Opportunities await budding researchers! In the words of Thomas Edison: ‘Opportunity is missed by most people because it is dressed in overalls and looks like work.’
SC
Dexmedetomidine sedation for a dental extraction in a patient with known difficult airway
Guiness F, Coleman M, Gillbride M. Association of Anaesthetists.
Anaesthesia Reports.2022;10:2
Abstract
Fibrodysplasia ossificans progressiva is an autosomal dominant condition that causes cervical spine fusion and ankylosis of the temporomandibular joint, resulting in anaesthetic challenges. Awake tracheal intubation with flexible bronchoscopy is recommended for general anaesthetics required by patients with this disease. This case report describes the novel approach of using dexmedetomidine sedation in combination with local anaesthesia to allow dental extraction of the fifth and seventh upper left teeth in a patient with fibrodyplasia ossificans progressiva, who had a known difficult airway and profound thrombocytopenia. This procedure was not previously tolerated by the patient under local anaesthesia alone. The use of dexmedetomidine was successful in facilitating completion of the procedure with a high degree of patient satisfaction. We discuss the advantages of dexmedetomidine over other sedative agents due to its minimal effects on respiratory drive and airway muscle tone. We highlight the use of dexmedetomidine for complex cases such as this, where tracheal intubation is potentially challenging, but the procedure itself could be managed under sedation and local anaesthesia.
Reviewer’s evaluation, opinion and points of interest
Within special care dentistry, we frequently encounter patients with difficult airways and work with our colleagues in anaesthesia to risk manage complex situations. I found this article thought- provoking, not only for highlighting the challenges of this rare disorder, but also for the discussion of considerations during risk assessment and steps taken by the team to mitigate the situation.
The authors describe the benefits of dexmedetomidine as a sedative in this difficult scenario. This drug is an imidazole compound that has specific alpha-2 adrenoceptor agonist activity. It has favourable properties as a sedative agent as it provides anterograde amnesia, anxiolysis and analgesia. It can be administered through a variety of routes, typically based on weight. Although dexmedetomidine is reported to have minimal effects on respiration and muscle tone, it is considered to have some detrimental effect on haemodynamic stability including bradycardia and hypotension.
The commentary following this publication was equally interesting (Jia, T and Teng, J. Comment on ‘Dexmedetomidine sedation for a dental extraction in a patient with known difficult airway’ Anaesthesia Reports. 11, e12200 (2023)). It was suggested that dexmedetomidine use is limited, particularly in older patients and those with haemodynamic instability and there was a suggestion that in general, alternative sedatives may have less physiological impact on patients and a faster recovery, including remimazolam. Remimazolam has recently become a hot topic due to its rapid onset and short duration of action making it an ideal sedative for short procedures. At present, there is limited literature available specific to dental procedures however, it is anticipated that this will increase especially in the UK for suitable cases following the 2023 statement on clinical use and training from the Intercollegiate Advisory Committee for Sedation in Dentistry regarding the use of this drug. Let’s watch this space…
SC