Effectiveness of premedication agents administered prior to nitrous oxide/oxygen

In pediatric dentistry, sedation procedures are required when there is no possibility to carry out dental treatments because of anxiety, dental fear or behavioral impairments. However, sedation at the desired level might not be achieved despite administration of various agents. The present study aims to evaluate the effectiveness of oral premedication with different agents on children scheduled for dental treatment under nitrous oxide/oxygen (N2O/O2) sedation.This research was approved by Gazi University Faculty of Medicine Ethical Committee. 60 children aged between 5-8 years, corresponding to ASA I or II, having no mental or motor retardation, requiring at least 2 visit-dental treatment, having no sedation or general anesthesia experience and incompliant with dental treatment (Frankl Behavior Scale?3) were enrolled to the study after obtaining informed parental consent. Then the children were randomly assigned to 1 of 4 groups. The treatment regime according to the study groups was as follows: oral administration of 1 mg.kg-1 hydroxizine hydrochloride suspension (AtaraxÒ) 1 hour preoperatively (group I, n=15), oral administration of 0.7 mg.kg-1 midazolam HCl (DormicumÒ) 15 minutes preoperatively (group II, n=15), oral administration of 3 mg.kg-1 ketamine (KetalarÒ)+0.25 mg.kg-1 midazolam HCl (DormicumÒ) 15 minutes preoperatively (group III, n=15) and no oral premedication was administered to the control group (group IV, n=15). Peripheral oxygen saturation (SpO2) and heart rate (HR) were monitored with pulse oximeter (TuffSATÒ, Datex-Ohmeda) during treatment. Sedation level was monitored with BIS (BIS® XP, Aspect). Following premedication, 40 % N2O and 60 % O2 were administered to all groups with nasal hood. Sedation depth was evaluated using Ramsay Sedation Scale (RSS) and data were recorded at 5-minute intervals. The children?s sedation success during dental treatment was classified as: satisfactory (If RSS at any evaluation point was 2, 3 or 4 and dental treatment was performed successfully), middle level satisfactory (If RSS at any evaluation point 1, 2, 3 and treatment was performed with difficulty) or unsatisfactory (If RSS at any evaluation point 1 or 2 and dental treatment could not be performed due to agitation). Sedation success, and other sedation related events were recorded. Anxiety and sedation levels, recovery time of children in addition to satisfaction of parents and children were recorded postoperatively.The evaluation of the findings of this study revealed that treatment procedures were achieved without any serious complications. Achievement of sedation in terms of satisfactory/ middle level satisfactory/ unsatisfactory was as follows respectively: 13.3 % / 53.3 % / 33.3 % in group I, 54 % / 20 % / 26 % in group II, 33.3 % / 33.3 % / 33.3 % in group III and 6.7 % / 60 % / 33.3 % in group IV. With respect to BIS values, it was found that the subjects at N2O/O2 group were more awake and the deepest sleep was observed at ketamine+midazolam HCl group at the moment BIS sensor was placed. when the correlation between BIS and RSS scores was evaluated, it was concluded that the use of BIS in dental sedation practice increased the confidence level of sedation taking the 65% correlation into account. HSS and RSS results revealed that the most effective medication was 0.7 mg.kg-1 midazolam HCl.It is concluded that 0.7 mg.kg-1 midazolam HCl is more effective than 0.25 mg.kg-1 midazolam+3 mg.kg-1 ketamine and 1 mg.kg-1 hydroxizine hydrochloride in terms of oral premedication prior to N2O/O2 sedation in children scheduled for dental treatments.