口服咪达唑仑治疗牙科恐惧症儿童的临床疗效观察

目的对牙科恐惧症儿童实施口服咪达唑仑镇静下的口腔治疗,评估治疗的安全性、有效性及其影响因素。方法选择在口腔科就诊的Frankl量表评分为1的有不良牙科治疗经历的30例患儿为研究对象,共进行了46人次的口服咪达唑仑（0.5～1.0 mg·kg-1）镇静下治疗。治疗时,记录患儿的心率、血氧饱和度、治疗内容及持续时间等。采用Houpt量表评估患儿治疗完成情况,治疗结束24 h后电话回访不良反应。结果46人次治疗中,患儿的生命体征平稳、安全,37人次（80.4％）完成了既定治疗,9人次（19.6％）镇静效果不理想,仅完成部分治疗。烦躁不安是术后最常见的不良反应。3岁以上儿童的治疗成功率高于3岁及以下儿童,性别、剂量和治疗内容与治疗成功率无关。结论口服咪达唑仑治疗牙科恐惧症儿童是一种安全有效的方法,3岁以上儿童的治疗效果较好。     

Rectal administration of midazolam for conscious sedation of uncooperative children in need of dental treatment

The aim of this study was to determine the effects of rectal midazolam on uncooperative children. The trial included 120 children at the age of 16 months to 10 years and six months (X = 4.5 years). The children were referred because behavioural management techniques alone had failed. On 225 treatment occasions the children received midazolam, 0.3 mg/kg body weight rectally 10 mins before treatment. The degree of sedation was assessed by the dentists after 10, 15, 20, 45 and 60 minutes. 60% of the treatments were fulfilled without difficulty. 39.6% of the treatments could be performed with some difficulty and with the help of parents preventive holding. Only one mentally handicapped patient showed non-acceptance. No side effects were noted during the treatments. After 107 treatments the parents were asked about the total time their children seemed sedated. After two hours 86 children were still considered sedated but after three hours only four of them seemed effected by the drug. Midazolam has shown in this follow-up to be an effective and safe drug for premedication of infants in the stressed dental situation. The advantage to for example diazepam lies mainly in the shorter period of time of sedation.     

Conscious sedation by oral administration of midazolam in paediatric dental treatment

Midazolam is a short-acting benzodiazepine with rapid onset, short duration of action and minimal side effects. The aim of this study was to evaluate the oral administration of midazolam as pre-operative sedation in the dental treatment of uncooperative pediatric patients. Included in the study were 160 children with a mean age of 6.7 +/- 2.6 years (1-14 years), 83 boys and 77 girls. All the patients had been referred for specialist treatment due to behavioral management problems. Treatment was performed in 250 sessions. All the children received an oral dose of 0.2 mg/kg body weight of midazolam. Acceptance of treatment was evaluated according to Rud & Kisling. Local anesthesia followed by restorative treatment and/or extractions constituted more than 90% of the performed treatments. Of the 250 sessions, 63% were performed with total acceptance and 30% with doubtful acceptance. In 7%, no treatment could be performed. No serious complications were registered during or after treatment. All the children were able to leave the clinic one hour after treatment. In conclusion, we consider oral administration of midazolam a safe form of premedication. The route of administration, the short waiting-time and half-life, in combination with a level of sedation that allows treatment to be performed, are the principal advantages of conscious sedation with orally administered midazolam.     

103例口腔患儿应用笑气镇静的临床效果

目的:观察笑气吸入法在儿童牙科临床治疗效果.方法:选取有牙科焦虑症,行为表现分级为Venham 2 ～4级患儿103例,经患儿家长同意采取笑气吸入,记录每次镇静治疗时患儿的心率、血氧饱和度、呼吸频率,评定笑气吸入在儿童牙科的镇静效果.结果:93例Venham 2～4级患儿笑气吸入后口腔治疗基本顺利进行,10例Venham 4级患儿不能配合治疗,改为束缚下治疗.结论:笑气吸入法能够减轻或缓解患儿对牙科的恐惧和不安,是一种有效的镇静方法.     

静脉泵入咪达唑仑清醒镇静技术控制牙科恐惧症的临床效果评价

目的评价静脉泵入咪达唑仑控制牙科恐惧症的临床效果。方法选择31例对牙科治疗极度恐惧但能与医师良好沟通的患者,将其两侧需行根管治疗的2颗患牙分别纳入试验组和对照组,对照组为常规牙科治疗,试验组加用咪达唑仑静脉泵入清醒镇静技术,控制患者治疗过程中的恐惧。评价两组患者的治疗依从性和行为治疗效果,并观察试验组患者生命体征的变化及副作用的发生率。结果试验组、对照组的Houpt行为治疗效果评分和Frankl治疗依从性评分均存在显著性差异（z=- 4.846,P=0.000;z=- 4.907,P=0.000）。试验组患者采用镇静措施后血压、心率均有轻度降低,并有轻度的呼吸抑制,但不影响治疗完成。结论单纯咪达唑仑静脉镇静对于能够良好沟通、主观愿意配合的极度牙科恐惧患者具有较好的疗效。     

An objective criteria used to support a practitioner's decision between sedation versus general anesthesia for the dental treatment of uncooperative pediatric patients

PurposeThis purpose of this study was to create a criteria and assess its performance with the results as to use of conscious sedation versus general anesthesia for dental care of uncooperative pediatric patients.MethodsA retrospective study was designed to include children who received dental care under GA (General Anesthesia) or CS (Conscious Sedation) over a one year period in Newark, NJ. A study sample size of 80 children was created according to a power analysis used to yield a sample with 80% power at the 0.05 significance level. Children were divided into two groups. 35 subjects were in the CS group and 45 in GA group. For each child; the total score of the suggested criteria was calculated using the collected data. The suggested criteria combined seven scales, the criteria's total score is the sum of the seven scales' scores. The scale was designed such that a higher score would indicate the need for GA rather than CS. The criteria was designed to indicate the use of GA when the total score is 16 points or higher.ResultsThis evaluation showed that there is a positive correlation between the proposed criteria and the decision made retrospectively to use GA versus CS for uncooperative children needing dental care.ConclusionThe scale is a valid indicator of the need for GA versus CS, except for a child's age.     

Prediction of success and failure of behavior modification as treatment for dental anxiety

Behavior modification techniques are effective in the treatment of extreme dental anxiety, but their success is by no means absolute. In the present article, the Corah Dental Anxiety Scale (DAS), the self-report symptom inventory SCL-90R and a questionnaire accessing subjects' daydreaming styles (the Short Imaginal Process Inventory) were used to develop possible predictive measures for success and failure of behavior modification as a treatment for dental fear. The patients' level of distractibility and mind wandering, initial dental anxiety and somatization significantly predicted the success of therapy. The odds ratio indicated that the risk of therapy failure increased about 11 times with an increase of one scale of the Poor Attention Control Scale, about three times with an increase of one level of the mean DAS score, and 0.17 times with an increase of one level of somatization. The predictive value of the chosen scales was 80%. Thus, the use of these scales as part of an initial admittance process for patients who suffer from dental anxiety can enhance our ability to better recognize patients who are prone to fail behavior therapy as treatment for their problem, and enable their referral for other possible modes of treatment.     

Social supports and prevention strategies as adjuncts and alternatives to sedation and anesthesia for people with special needs

People with special needs are assuming a more prominent place in our society. The number of people living in communities with medical, physical, and psychological conditions is increasing dramatically. In spite of the advances that people with special needs have made in recognition of their right to live in society and access services open to other people, their oral health is still significantly poorer than that of other groups.
There are a number of modalities that can complement or replace pharmacological interventions and allow individuals to have dental treatment in a dental office or clinic. These include behavioral or psychological interventions and social support and prevention strategies. Social supports include care management and integration of oral health services with general health and social service systems.
Preventive programs using modern "medical model" oral health prevention strategies also have the potential to reduce the burden of disease among people with special needs and therefore reduce the need for dental procedures. A social support system using community-based Dental Hygienists acting as Dental Coordinators, is described along with outcomes demonstrating improved oral health for people with special needs living in community residential care facilities. Combined social support systems and community prevention strategies have the potential to reduce the need for pharmacological interventions in order to maintain oral health in populations of people with special needs. Social supports and modern preventive strategies must be included in the range of options available in communities in order to improve and maintain oral health for people with special needs.     

An RCT pilot study to test the effects of intravenous midazolam as a conscious sedation technique for anxious children requiring dental treatment--an alternative to general anaesthesia

AIM: To add to the evidence base for acceptable and effective paediatric conscious sedation techniques in dental primary care. OBJECTIVES: To compare three conscious sedation techniques for primary care as an alternative to dental general anaesthesia (DGA) in children. To assess the feasibility and practicality of running the trial in general dental practice. To form the basis for sample size calculations and assess scales of measurement. DESIGN: Single centre, randomised control trial (RCT). SETTING: Queensway Anxiety Management Clinic (QAMC). A primary care based general and referral dental practice for the management of anxious patients. SUBJECTS, MATERIALS AND METHODS: Sixty five children too anxious for management with relative analgesia, requiring invasive dental procedure for which dental general anaesthesia (DGA) will be required if an alternative cannot be found. INTERVENTIONS: Group 1 (n = 20) - A combination of inhaled medical air and titrated intravenous midazolam. Group 2 (n = 22) - A combination of inhaled 40% nitrous oxide in oxygen and titrated intravenous midazolam. Group 3 (n = 23) - A combination of an inhaled mixture of 0.3% sevoflurane and 40% nitrous oxide in oxygen with titrated intravenous midazolam. MAIN OUTCOME MEASURES: Successful completion of the intended dental treatment with a child who is co-operative and responsive to verbal commands. RESULTS: Fifty per cent (ten children) successfully completed treatment in Group 1, 73% (16 children) in Group 2 and 83% (19 children) in Group 3. This difference was not significant at a 5% level (chi(2) = 5.53, df = 2, P = 0.07) Of the total of 20 failures, eight children in Group 1 and one child in Group 2 were successfully treated with the addition of sevoflurane and nitrous oxide in oxygen. Only two children required referral to a hospital setting for DGA and the remaining nine children were managed with an alternative conscious sedation technique. CONCLUSION: This pilot shows that intravenous midazolam especially in combination with the addition of inhaled nitrous oxide or sevoflurane and nitrous oxide were promising safe and effective techniques, sufficient to justify progression to a definitive RCT with appropriate methods.     

全身麻醉下儿童牙齿治疗技术在我国应用现状及展望

国际上开展全身麻醉下儿童牙齿治疗已经有60多年历史,其技术越来越成熟,效果也得到了广泛肯定。我国从90年代末期开始一些医院相继开展此项技术,近年来有了长足发展,许多医院已开始或准备开展全身麻醉下儿童牙齿治疗,大部分开展此项技术的医院都出现了患者排队数月甚至更长时间的情况。该文将介绍全身麻醉下儿童牙齿治疗的国内外情况,适应证和禁忌证、风险防范和规范制定以及未来展望。     

The dental patient with special needs: a review of indications for treatment under general anesthesia

General anesthesia (GA) can play an important role in the facilitation of dental treatment for individuals who present with challenging behaviors. This article presents a review of the literature discussing indications for the utilization of GA in the treatment of dental patients with special needs.     

Cardiovascular responses to different stages of restorative dental treatment unaffected by local anaesthetic type

Background: The aim of this study was to evaluate the cardiovascular effects of maxillary infiltration using 2% lidocaine with 1:100 000 adrenaline, 4% articaine with 1:200 000 adrenaline, and 4% articaine with 1:100 000 adrenaline in different stages during restorative dental procedures. Methods: Twenty healthy patients randomly received 1.8 mL of the three local anaesthetics. Systolic blood pressure, average blood pressure, diastolic blood pressure, and heart rate were evaluated by the oscillometric and photoplethysmograph methods in seven stages during the appointment. Results: Statistical analysis by ANOVA and Tukey tests of cardiovascular parameters did not show significant differences between the anaesthetic associations. There were significant differences for the parameters among different clinical stages. Conclusions: The variation of cardiovascular parameters was similar for lidocaine and articaine with both adrenaline concentrations and showed no advantage of one drug over the other. Cardiovascular parameters were influenced by the stages of the dental procedures, which showed the effect of anxiety during restorative dental treatment.     

重度低龄儿童龋儿童全身麻醉与常规门诊下牙病治疗的疗效及卫生经济学评价

对牙科全身麻醉（DGA）下和常规门诊治疗的重度低龄儿童龋（S-ECC）进行临床疗效及卫生经济学评价,为医生和家长的临床治疗方案选择提供参考。     

Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia

OBJECTIVE: This paper examines the cost to the Iowa Medicaid program of hospitalizing young children for restorative dental care under general anesthesia, and describes the dental services received in this setting. METHODS: Medicaid dental claims for young children receiving restorative dental care under general anesthesia during fiscal year 1994 were matched with corresponding hospital and anesthesia claims. RESULTS: The total cost to the Medicaid program of treating a child in the hospital under general anesthesia was $2,009 per case. Less than 2 percent of Medicaid-enrolled children under 6 years of age who received any dental service accounted for 25 percent of all dollars spent on dental services for this age group, including hospital and anesthesia care. The most frequent type of procedure was stainless steel crowns (SSCs), with an average of almost six per case. CONCLUSIONS: Early identification, prevention, and intervention are critically important to prevent the costly treatment of children with ECC in hospital operating rooms.     

The use of nitrous oxide-oxygen inhalation sedation with local anaesthesia as an alternative to general anaesthesia for dental extractions in children

The aim of this study was to determine whether children who were assessed to require the extraction of teeth under general anaesthetic could be treated using an alternative technique of nitrous oxide-oxygen inhalation sedation with local anaesthetic. Consent was obtained for 61 children to enter the study. Fifty-three children were treated successfully using inhalation sedation and local anaesthetic. It was evident that general anaesthetic facilities would still be required for a small proportion of children who could not cooperate adequately for treatment to be performed under sedation and local anaesthetic.