Temperament and acceptance of dental treatment under sedation in preschool children

The major aim of the study was to investigate whether differences concerning acceptance of dental treatment and amnesia after rectal sedation with midazolam can be explained by temperament traits in the child. Fifty children (1.5 4.0 years), consecutively referred for dental extractions because of dental trauma or caries, were sedated with midazolam 0.3 mg kg(-1) rectally. Level of sedation (state of mind) was assessed according to Wilton before and 10 min after administration of the sedative. The children's acceptance of procedures during the oral examination, the administration of the sedative, and the dental treatment were assessed according to Holst. Acceptance of an injection of local anesthesia and tooth extraction was dichotomized as satisfactory (n = 26) or unsatisfactory (n = 24). The parent assessed temperament using the Emotionality Activity Sociability (EAS) Scale of Child Temperament. Amnesia was evaluated by the parent on the following day. The relation between temperament and outcome variables was analyzed using a multiple logistic regression analysis. Children regarded as shy by the parent were at significantly greater risk of unsatisfactory acceptance of the dental treatment (P< 0.05). High scores of negative emotionality were significantly related to less amnesia (P < 0.05). We conclude that parental ratings of their child's temperament are valuable in predicting a child's acceptance of dental treatment under sedation.     

Rectal sedation with diazepam or midazolam during extractions of traumatized primary incisors: a prospective,randomized, double-blind trial in Swedish children aged 1.5-3.5 years

The aim of this study was to compare rectal sedation with diazepam and rectal sedation with midazolam with regard to sedative effect, treatment acceptance, and amnesia. Ninety children, 1.5-3.5 years of age, consecutively referred for extractions of traumatized primary incisors were randomly sedated with diazepam (0.7 mg/kg body weight) or midazolam (0.3 mg/kg body weight). The study design was randomized and double-blind. The level of sedation (state of mind) was assessed prior to and 10 and 60 min after administration of the drug by use of a behavioral scale (Wilton). The children's acceptance of procedures was assessed using another behavioral scale (Holst) during administration of the sedative, application of topical anesthesia, injection of a local anesthesia, and extraction. Amnesia was evaluated by the parents on the following day, with the child being asked standardized questions. Parental ratings of the child's and their own distress during and after treatment were made on a visual analog scale (VAS). No differences were found between the sedatives concerning level of sedation during treatment, acceptance of procedures, or amnesia. At discharge, 60 min after administration of the sedative, the children receiving diazepam were significantly more agitated (P = 0.006). Parental rating on a VAS of the child's discomfort after treatment was significantly higher in the diazepam group (P = 0.006). There was a tendency for children with poor acceptance of the rectal administration to display a more negative acceptance of the dental treatment. In conclusion, the present results, in combination with known pharmacological advantages, indicate that midazolam is preferable in outpatients when sedation is needed and amnesia is desirable.     

Acceptance of dental care following early extractions under rectal sedation with diazepam in preschool children

The aim of the study was to evaluate the effect of amnesia in preschool children on their later acceptance of dental care. Forty-six 4-6-year-old children, who between 2 and 4 years previously had had primary incisors extracted because of trauma, were reexamined for dental health and acceptance of dental care. The extractions had been performed under rectal sedation with diazepam (0.7 mg/kg body weight). Information about dental treatment and degree of cooperation during the intervening period was obtained from records at the referring clinic. The parents were interviewed about their child's experience of amnesia concerning the extractions, background variables, and experiences of dental care before the follow-up examination. Amnesia concerning the extractions was reported in 85% of the children. Twenty-nine percent had on some occasion exhibited behavior management problems (BMP) during the intervening period. Lack of amnesia was significantly associated with BMP (P &lt; 0.002). Children without amnesia concerning the extractions tended to accept dental care less well at the reexamination. Parents were able to predict their child's acceptance of dental care at the follow-up with a significant degree of success (P = 0.02). In conclusion, amnesia in preschool children concerning extractions seems to be essential to facilitate positive acceptance of future dental care.     

Rectal sedation with diazepam or midazolam during extractions of traumatized primary incisors: a prospective, randomized, double-blind trial in Swedish children aged 1.5-3.5 years.

The aim of this study was to compare rectal sedation with diazepam and rectal sedation with midazolam with regard to sedative effect, treatment acceptance, and amnesia. Ninety children, 1.5-3.5 years of age, consecutively referred for extractions of traumatized primary incisors were randomly sedated with diazepam (0.7 mg/kg body weight) or midazolam (0.3 mg/kg body weight). The study design was randomized and double-blind. The level of sedation (state of mind) was assessed prior to and 10 and 60 min after administration of the drug by use of a behavioral scale (Wilton). The children's acceptance of procedures was assessed using another behavioral scale (Holst) during administration of the sedative, application of topical anesthesia, injection of a local anesthesia, and extraction. Amnesia was evaluated by the parents on the following day, with the child being asked standardized questions. Parental ratings of the child's and their own distress during and after treatment were made on a visual analog scale (VAS). No differences were found between the sedatives concerning level of sedation during treatment, acceptance of procedures, or amnesia. At discharge, 60 min after administration of the sedative, the children receiving diazepam were significantly more agitated (P=0.006). Parental rating on a VAS of the child's discomfort after treatment was significantly higher in the diazepam group (P=0.006). There was a tendency for children with poor acceptance of the rectal administration to display a more negative acceptance of the dental treatment. In conclusion, the present results, in combination with known pharmacological advantages, indicate that midazolam is preferable in outpatients when sedation is needed and amnesia is desirable.     

Combined oral midazolam–ketamine better than midazolam alone for sedation of young children: a randomized controlled trial

International Journal of Paediatric Dentistry 2013; 23: 207–215 Background. There is a lack of clinical trials on paediatric dental sedation. Aim. We investigated whether young children’s behaviour improves during dental treatment with oral ketamine/midazolam compared with midazolam alone or no sedation. Design. Healthy children under 36 months of age, presenting early childhood caries were randomly assigned to receive protective stabilization plus: combined oral midazolam (0.5 mg/kg) and ketamine (3 mg/kg) (MK), or oral midazolam (1.0 mg/kg) (MS), or no sedative (PS). One observer scored children’s behaviour using the Ohio State University Behavior Rating Scale (OSUBRS) at determined points in a dental exam (no sedative) and treatment session. Data were analysed using nonparametric bivariate tests. Results. Forty‐one children were included. In the dental exam session, the sum of OSUBRS scores was similar for the three groups (P = 0.81). In the treatment session, the MK produced more cooperative behaviour than MS and PS (P = 0.01), longer sessions (P = 0.04), and a pattern of homogeneous OSUBRS scores from the reception area (before sedative administration) to the end of the session (P = 0.06). No immediate and post‐discharge side effects were observed in groups MK and MS. Conclusions. The combination of oral midazolam and ketamine is efficacious for guiding the behaviour of children under 3 years old.     

Optimising the dose of oral midazolam sedation for dental procedures in children: a prospective, randomised, and controlled study

International Journal of Paediatric Dentistry 2012; 22: 271–279 Background. Midazolam sedation poses a significant dilemma in paediatric dentistry, which is to find out the optimal dosing with minimal undesirable adverse events. In this study, we aimed to compare the effect of three doses of oral midazolam (0.5, 0.75, and 1 mg/kg) on the sedative state and cooperative behaviour of children during dental treatment. We further compared completion rates, parent satisfaction, and all adverse events. Design. Ninety children aged 3–10 years were randomised to three equal groups. Groups A, B, and C received 0.5, 0.75, and 1 mg/kg of oral midazolam, respectively. Levels of sedation, cooperative behaviour, procedures completion rates, parent satisfaction, and adverse events were prospectively recorded. Results. Sedation scores in B and C were higher (P < 0.001) than in A. Cooperation scores (CS) in B and C were higher (P < 0.001) than in A. Significant increase in completion rates was observed between A and C (P = 0.025). Parent satisfaction was greater in B and C (P < 0.001) compared to A. Adverse events were higher in C (P < 0.05) than in A or B. Conclusion. Amount of 0.75 mg/kg oral midazolam appears to be the optimal oral dose in terms of effectiveness, acceptability, and safety for dental treatments in paediatric patients, when administered by an experienced, paediatric anaesthetist.     

The use of temazepam elixir in surgical dental sedation: a comparison with intravenous midazolam.

Out-patients attending for removal of at least one lower third molar were randomly allocated to treatment with temazepam elixir (n = 7) or intravenous midazolam (n = 8), as well as local analgesia. Patients were tested prior to drug administration and at the end of surgery. Both drugs increased heart rate and midazolam also decreased diastolic blood pressure. The two drugs caused significant, equal increases in ratings of sedation, but the reduction of anxiety was significant only for midazolam. There was significant amnesia for material presented after drug administration, as well as for dental events and this was significantly greater for midazolam. The effects of these drugs in dental patients were compared with those in normal volunteers treated in an identical manner, but without oral surgery. The drugs had similar significant cardiovascular and amnesic effects in the volunteers and the same effects on mood ratings, even though volunteers and patients differed in their pretreatment levels of anxiety and discontent. The dentist's ratings of the sedation and operating conditions were excellent in both cases. Thus temazepam elixir provided a useful sedative for oral surgery, avoiding the complications of intravenous administration. However, for equivalent levels of sedation, midazolam had greater anxiolytic and amnesic effects than temazepam.     

A comparative evaluation of oral midazolam with other sedatives as premedication in pediatric dentistry

The purpose of present study was to evaluate the safety and efficacy of orally administered midazolam in children as a sedative agent and to compare it with two other older agents, triclofos and promethazine. The study was conducted on ninety child patients requiring some short dental procedure. All the patients were with a good physical status (ASA-I). The ages ranged between 3 and 9 years. The patients were randomized into three study groups: Group 1, midazolam, Group II, triclofos and Group III, promethazine, on the basis of the drugs to be administered. After administration of drugs in each group, the effects were evaluated in terms of onset of action, sedative effect, ease of treatment completion, recovery time and postoperative amnesia. Midazolam was found to be the best drug among the three to produce conscious sedation in children.     

Midazolam, diazepam, and placebo as intravenous sedatives for dental surgery

This study was a comparison of the sedative and amnestic properties of midazolam and diazepam when administered for relief of patient discomfort during dental surgery. It was a double-blind placebo-controlled group study, which entailed the analysis of 60 patients randomly assigned to the three groups: midazolam, diazepam, and placebo. There were 20 patients in each group. Midazolam patients showed superior performance in the parameters of sedation and amnesia when compared to patients who were administered diazepam. Both groups showed better results than the placebo group, which had the best results with the Digit Symbol Substitution Test and the Trieger Test.     

Psychoprophylaxis for oral conscious sedation for dental care in Down syndrome adults with behavioral disorder

Down syndrome (DS) presents with prevalent diseases in the oral cavity and the need of constant dental care and follow‐up. The use of conscious sedation (CS) for dental care in adult DS with behavioral disorders is poorly documented. The aim of this study was to evaluate the effectiveness and safety of CS procedures with oral midazolam using previous psychoprophylaxis sessions in DS adult patients with behavioral disorders. Methods: Twenty‐nine DS adults with behavioral disorders. The patients were managed with psychoprophylaxis followed by oral CS using 15 or 30 mg midazolam. Vital parameters were monitored. The Houpt and Brietkopf and Buttner scales were used. Results: Patients under CS received an initial dose of 15 mg midazolam; however, 51.72% needed a 30 mg dose at the following sessions. Results showed that 71.4% treated with the 15 mg dose had Houpt scale overall behavior scores of 4 or 5, while 93.33% of those receiving 30 mg had scores of 5 or 6 (chi‐square = 15.95 p < .01). Conclusion: Psychoprophylaxis sessions followed by CS procedures using oral midazolam in adult DS with behavioral disorders were shown to be a useful strategy to perform routine dental treatment safely. Midazolam produces anterograde amnesia, and participants were more cooperative in the following visits.     

Comparison of oral ketamine and oral midazolam as sedative agents in pediatric dentistry

The safe and effective treatment of uncooperative or combative preschool children with extensive dental needs is one of pediatric dentist's ongoing challenges. The traditional methods of behavior management are no longer acceptable to parents as they are not ready to spare more time for dental treatment of their children. Keeping this in mind, the present study was designed and carried out to evaluate the sedative effects of oral ketamine and oral midazolam prior to general anesthesia. Twenty uncooperative children in the age-group of 2-6 years were selected after thorough medical examination and investigations. Informed consent was obtained from the parent. This was a randomized double-blind study. An anesthesiologist administered either 0.5 mg/kg midazolam or 5 mg/kg ketamine orally. The heart rate, respiratory rate, and oxygen saturation were recorded at regular intervals. The sedation and anxiolysis scores were also recorded. The parents were asked to answer a questionnaire at the follow-up session the next day on the surgical experience of the parent and the child and side effects experienced, if any. When the data was subjected to statistical analysis, it was observed that both drugs resulted in adequate sedation at the end of 30 min, with oral midazolam providing significantly better anxiolysis. The heart rate and respiratory rate were marginally higher with oral ketamine. The questionnaire revealed a better response with oral midazolam; side effects were more prominent with oral ketamine.     

Reversal of midazolam sedation with flumazenil following conservative dentistry

The purpose of this double-blind randomized study was to assess recovery of mental function following reversal of midazolam-induced sedation with the specific antagonist flumazenil (R015-1788) or placebo following conservative dental procedures. Recovery was assessed using choice reaction time and critical flicker fusion threshold, both objective tests of psychomotor function; linear analogue sedation scores and simple memory tests. Assessments were repeated up to 3 h after administration of flumazenil or placebo to discover whether recovery was sustained or whether resedation occurred due to the short duration of action of flumazenil. Flumazenil in doses from 0.5 to 1.0 mg rapidly reversed the sedative and amnesic effects of a mean dose of 8.2 mg of midazolam without apparent evidence of subsequent resedation. Since recovery of mental function in the control group had ordinarily occurred 45 min after administration of placebo, routine reversal of midazolam sedation with flumazenil cannot be justified. Nevertheless, in cases of undue sedation persisting after dental treatment, flumazenil may be used with minimal risk of resedation occurring.     

口服与肌注咪达唑仑镇静治疗儿童牙科焦虑症的临床疗效对比

目的:评估咪达唑仑口服或肌注两种不同给药方法对牙科焦虑症患儿牙科治疗时的镇静效果。方法:将2020年1月~2020年7月于深圳市儿童医院口腔科接受咪达唑仑镇静下牙齿治疗的90例患儿随机分为两组,每组45例。肌注组给予肌注咪达唑仑(0.2 mg/kg),口服组给予口服咪达唑仑(0.6 mg/kg,单次最大剂量20.0 mg)。采用Ramssay量表评估患儿镇静情况,Frankl量表评估患儿治疗依从性,Houpt量表评估患儿治疗完成情况。同时记录药物起效时间、患儿治疗过程中的心率、血氧饱和度、术中及术后不良反应情况等。结果:肌注组起效时间(13.0±2.0)min明显短于口服组(15.6±1.8)min,差异有统计学意义(t=6.489,P<0.05)。两组的Ramssay量表评分中位分值(Z=-1.089,P=0.276),Frankl量表评分中位分值(Z=-0.0863,P=0.388)及Houpt量表评分中位分值(Z=-1.854,P=0.064)差异无统计学意义(P>0.05),评分分布相似。两组患儿的镇静成功率(χ^2=0.178,P>0.05)及治疗成功率(χ^2=3.103,P>0.05)差异无统计学意义(P>0.05)。两组不良反应发生率差异无统计学意义(χ^2=0.080,P>0.05)。结论:口服或肌注咪达唑仑镇静效果相似,是治疗牙科焦虑症患儿的安全有效的镇静方法,但肌注组的镇静起效更快。     

The effects of midazolam on pediatric patients with asthma

PURPOSE: This study was performed to evaluate the safety and efficacy of midazolam in asthmatic patients undergoing dental treatment. METHODS: Twenty-four children, aged 19 to 65 months, with a diagnosis of mild to moderate asthma were given an oral dose of 0.5 mg/kg of midazolam. Oxygen saturation, respiratory rate, and pulse rate were monitored before, during, immediately after, and 30 minutes following dental treatment. The child's asthma score was also determined before and after treatment. The dental operator assessed the overall sedation outcome immediately after treatment. RESULTS: Twenty-three of the 24 subjects had asthma scores of "0" before and after treatment. During dental treatment, 2 patients had oxygen saturations of 94% at one point during treatment. However, oxygen saturation increased when the patient's head and neck were repositioned. Twenty-three of the 24 subjects had oxygen saturations above 95% at 30 minutes following treatment. Pulse rates and respiratory rates exhibited transitory increases, linked to when the child was stimulated. Statistical analysis was conducted from within subjects repeated measures via ANOVA and with a general linear model approach. No statistically significant differences occurred in oxygen saturation and respiratory rate. However, significant differences did occur in pulse rate between 5 and 10 minutes (mean difference=10+/-3.84) and between 10 and 15 minutes (mean difference=19+/-5.50), as expected. No statistically significant differences occurred in asthma score before and after treatment. Twelve subjects were assessed to have excellent behavior, 5 subjects were satisfactory, and 7 subjects were unsatisfactory. No treatment was aborted. CONCLUSIONS: With adherence to the AAPD's sedation guidelines, midazolam at a dose of 0.5 mg/kg is a safe and effective mean for sedation of patients with mild to moderate asthma.     

Conscious sedation by rectal administration of midazolam or midazolam plus ketamine as alternatives to general anesthesia for dental treatment of uncooperative children

The trial included 24 children (aged 2–7 yr) referred for dental treatment under general anesthesia, since conventional behavioral management methods had failed to achieve treatment acceptance. As an alternative, they received, on two separate occasions with "identical" dental treatment, conscious sedation by rectal administration of either midazolam (0.3 mg/kg body weight (bwt)) or midazolam (0.3 mg/kg bwt) plus ketamine (1.0 mg/kg bwt). This allowed a double-blind, crossover design. The aims were to assess conscious sedation, combined with local anesthesia, as an alternative to general anesthesia, and further to evaluate the effects obtained by addition of a low dose of ketamine to rectally administered midazolam. The feasibility of dental treatment was rated as excellent or good for 16 of the 24 children when premedicated with midazolam, and for 18 of the 24 children when ketamine was added to midazolam. At least some treatment could be given to all children. Verbal contact was maintained with all children throughout both treatment sessions. The children were significantly less anxious when they arrived for the second session. Amnesia and drowsiness were significantly increased when ketamine was added to midazolam. The combination also tended to be more efficient in relief of anxiety and prevention of pain, but there were large variations in the children's responses to the drugs. Midazolam significantly reduced the blood oxygen level, but not with ketamine added. For most children, both regimens proved to be appropriate as alternatives to general anesthesia. From a pharmacologic point of view, the combination of midazolam and ketamine appears to be reasonable because 1) both drugs have sedative and amnestic properties, 2) ketamine adds an analgesic component, 3) midazolam counteracts the psychic side-effects of ketamine, and 4) ketamine counteracts the depressive effects of midazolam on vital body functions (respiration and circulation).     

右美托咪定与几种镇静药物在口腔门诊手术中镇静效果的meta分析

目的:采用meta分析,比较右美托咪定与咪达唑仑、氯胺酮和安慰剂在口腔门诊手术中的镇静效果。方法:计算机检索PubMed、Embase、Cochrane Library、Web of Science,检索时间从建库至2017年10月。收集口腔门诊手术中比较右美托咪定与咪达唑仑、氯胺酮或安慰剂镇静效果的随机对照试验（RCT）。采用Cochrane协作网系统评价法评价纳入文献质量,采用RevMan5.3软件对收集的患者资料进行meta分析。结果:共纳入12篇RCT、678例患者。Meta分析结果显示,右美托咪定组儿童的镇静评分低于生理盐水组(SMD=-1.73,95%CI:-2.70~-0.77,P=0.0004);右美托咪定组成人的镇静评分也低于生理盐水组(SMD=-2.23,95%CI:-4.39~-0.08,P=0.04);右美托咪定组儿童的镇静满意度与氯胺酮组无显著差异（RR=1.14,95%CI：1.00~1.30,P=0.05）;右美托咪定组儿童的镇静满意度优于咪达唑仑组（RR=1.38,95%CI：1.15~1.67,P=0.0006）;右美托咪定组成人的镇静满意度与咪达唑仑组无显著差异（RR=1.42,95%CI：0.86~2.33,P=0.17）;并且右美托咪定组儿童的行为满意度优于氯胺酮组（RR=1.19,95%CI：1.03~1.36,P=0.01）,也优于咪达唑仑组（RR=1.28,95%CI：1.07~1.54,P=0.008）。结论:与其他镇静药物相比,右美托咪定用于口腔门诊手术适度镇静可能是一种更好的选择。     

Oral health of young children in Mississippi Delta child care centers: a second look at early childhood caries risk assessment

Objectives: To identify the predictors of early childhood caries and urgent dental treatment need among primarily African‐American children in child care centers in the Delta region of Mississippi. The purpose of this study was to replicate predictors of caries and urgent dental treatment needs that were identified in an earlier study conducted in Delta child care centers and to assess additional caries risk factors not collected in the original study. Methods: Children in 19 child care centers were examined by the dentists, and the parents provided data on oral health practices, oral health history, and on children's oral health‐related quality of life (QOL). The dentists also assessed visible plaque and tested levels of mutans streptococci. Predictors of caries and treatment need among children 24 to 71 months of age were examined using logistic regression. Results: Two parent predictors of caries identified in the earlier study (parent flossing and soft/sugary drink consumption) were not predictive in the current study. Parent history of abscess continued to predict their child's urgent need for treatment. Young children's level of salivary mutans streptococci, maxillary incisor visible plaque, and parents' reports of child oral health‐related QOL measures predicted the presence of both caries and urgent treatment need. Some expected predictors, such as frequency of child's toothbrushing, were not predictive of caries. Conclusions: Parental abscess and parent's report of the child's oral health‐related QOL are risk indicators for poor oral health outcomes that could be used by nondental personnel to identify young children in need of early preventive intervention and dental referral.     

Factors associated with administration route when using midazolam for pediatric conscious sedation

Midazolam conscious sedation records of pediatric dental patients, one to six years of age, were reviewed retrospectively to: 1) examine the factors associated with the use of oral and nasal routes of administration and their effect on displayed behavior during dental treatment and 2) determine whether a child's compliance with oral administration is predictive of the intraoperative behavior displayed during dental treatment. Two hundred and fifty-seven conscious sedation records for 222 pediatric dental patients sedated with orally or nasally administered midazolam for dental treatment at the University of Florida were reviewed. Data collected included the patient's age, gender, route of administration, dose, compliance with oral administration, appointment type (planned vs. emergency), previous sedation experience with midazolam, operator vs. parent administration of the medication, use of papoose board and nitrous oxide/oxygen inhalation, types of procedures performed (restorations only, extractions only, or both), length of treatment rendered, and preoperative and intraoperative behavioral assessments of the child. The collected data were analyzed with Statview software using ANOVA and Chi-square analyses. There was a statistically significant difference (p < 0.001) between oral and nasal administration for the parameters of age, procedure length, appointment type, procedures performed, previous sedation experience and use of the papoose board and nitrous oxide/oxygen inhalation. While there was no statistically significant influence of chronological age on the preoperative Frankl behavior ratings, there was a statistically significant mean age difference with respect to the administrator of the medication (parent vs. operator), papoose board use, N2O/O2 use and previous sedation experience. Forty-five percent of the subjects were willing to accept oral administration of the medication, however, there was no statistically significant difference (p = 0.114) between the child's compliance to accept the medication and the intraoperative Frankl behavioral ratings displayed during dental treatment. In this review of midazolam conscious sedation records of pediatric dental patients. 1) route of administration was significantly influenced by several patient and procedural variables, resulting in different behavioral outcomes and 2) compliance with oral administration was not predictive of behavior displayed during treatment.     

Association of temperament with dental anxiety and behaviour of the preschool child during the initial dental visit

The aim of this study was to investigate whether there is an association between temperament characteristics of preschool children, dental anxiety, and their dental behaviour. A total of 100 children, aged 3–5 yr, who were attending their initial dental visit accompanied by a parent, were included in this cross‐sectional study. Dental anxiety of children was measured using the Facial Image Scale. The behaviour of children during the initial oral examination and oral prophylaxis was assessed using Frankl's behaviour rating scale. Temperament was assessed using Emotionality, Activity, Shyness Temperament Survey for Children (parental ratings). Statistically significant weak linear positive correlations were seen between the following: the percentage duration of definitely negative behaviour and shyness scores (r_s = 0.28); anxiety level and emotionality scores (r_s = 0.28); and anxiety level and shyness scores (r_s = 0.26). Multinomial logistic regression analysis revealed that children with higher anxiety had higher odds of showing definitely negative behaviour, which decreased with increasing age of the child. Emotionality and shyness temperaments may be weakly associated with dental anxiety, and shyness may be weakly associated with the dental behaviour of the preschool child. Definitely negative dental behaviour is associated with dental anxiety and age of the child.