Pediatric Dentistry. A Survey of Parental Perceptions of Conscious Sedation in Pediatric Dentistry in the Mid-South

Transcription

1 A Survey of Parental Perceptions of Conscious Sedation in Pediatric Dentistry in the Mid-South Journal: Pediatric Dentistry Manuscript ID: PediaD--0- Manuscript Type: Other Study Design: Cohort Study Keyword: Search for keywords from the website link above.: conscious sedation, pediatric dentistry, parents Reviewer Selection Topics: behavior management/psychology, sedation, dental education

2 Page of Pediatric Dentistry A Survey of Parental Perceptions of Conscious Sedation in Pediatric Dentistry in the Mid-South Purpose: To determine the thoughts and opinions parents have about oral sedation in the pediatric dentistry setting. Methods: A questionnaire was completed by parents in pediatric dentistry practices in the Mid-South. The questionnaire consisted of questions regarding sedation procedures, media coverage, and demographic information. Results: Of the surveys, were incomplete (n=). Fifty-eight percent of respondents indicated public insurance while % had some form of private insurance. Nearly half of respondents had a college/professional degree. Fortyeight percent of respondents had a child who had previously experienced sedation. Parents agreed or strongly agreed (%) that protective stabilization should not be necessary during a sedation. No parents reported that they thought sedation was unsafe. Seventy-three percent of parents reported being unaware of television or internet news coverage of sedation. Those who had been exposed to news coverage had no change in their views on sedation (%) or had a more favorable view of sedation (%). Conclusions: Parents believe sedation is safe in pediatric dentistry and believe that restraint should not be necessary. Parents desire to remain with their child during the appointment. Most parents in the Mid-South seem unaffected by any media coverage of dental sedation for children. INTRODUCTION Sedation is an integral part of treating children successfully in the pediatric dental setting. Many children are unable to cope with the process of having dental procedures completed without the assistance of behavior guidance techniques. These techniques vary significantly, from approaches as non-invasive as tell-showdo or positive reinforcement to advanced, invasive approaches such as pharmacologic sedation in the dental office or general anesthesia in an operating room. Fuhrer et al. states the dilemma as follows: The behavior of pediatric patients reflects fewer boundaries, less discipline and self control, and lowered behavior expectations by parents and society. This tendency

3 Page of toward poor behavior has placed pharmacologic methods of managing pediatric patients to the forefront. One traditional form of sedation seen in pediatric dentistry has been the administration of pharmacologic agents via the oral route. Enteral sedation has long been preferred to parenteral sedation when appropriate, due to its less invasive nature. Dialogue between the pediatric dentist and the parent becomes an important part of the process to complete treatment via oral sedation. Like any other situation, parents bring preconceived notions about sedation into the discussion with a pediatric dentist which may or may not be correct. Proper communication and the ability to address the concerns and misconceptions of the parent become an integral part of the overall process. Communication between the pediatric dentist and the parent becomes paramount, as it is possibly the most important source of information for the parent about the sedation process. This communication typically comes in the form of either a written form/pamphlet or through verbal communication. A study by Lawrence et al., showed that there was increased acceptance of different behavior guidance techniques when that technique was explained to the parent more extensively. Parents also felt the most informed when information about different techniques was presented to them verbally. An issue of concern facing the pediatric dental community is the occurrence of adverse outcomes during a conscious sedation visit. Access to news hours a day, as well as the accessibility of the internet in the past years has allowed parents to know when and where an adverse event occurs, many times without a

4 Page of Pediatric Dentistry geographic constraint. For example, a parent residing on the East Coast may be well aware of an adverse healthcare event that occurred on the West Coast. This directly affects the knowledge and opinions a parent brings into the discussion of sedation with the practitioner. This becomes another source of information for the parent, and could be factual and appropriate, however, it may be incorrect information or an opinion based on a faulty premise. Many studies have looked at the popularity and acceptance by parents of oral conscious sedation as compared to other methods on the behavior guidance continuum. Murphy et al. in found the most acceptable form of behavior guidance among parents to be tell-show-do with the least acceptable methods being passive restraint, oral sedation, and general anesthesia. Lawrence et al. in found a similar relationship among the different behavior guidance modalities. However, a 0 study by Eaton et al. showed an increase in acceptability for oral sedation and general anesthesia. That study also found no significant influence of age, gender, education level, or social status on parental opinion. The authors proposed that an increased exposure to surgical general anesthesia on television along with an increased familiarity with outpatient general anesthesia could be contributing to the increase in acceptability. Parenting styles have also changed significantly over the past few decades. This has led to a change in perception of an acceptable experience for a child at a dental visit. The views of society of what a child should or should not experience also have changed dramatically over the course of a few decades. The entire approach to parenting children in permissive environments and the concept of the

5 Page of child being in control of his situation at all times has had an effect on what is acceptable in many circumstances, including conscious oral sedation in a dental office. Aligned with this change in parenting styles is the increased presence of the parent in the operatory. In a survey by Wells et al., pediatric dental practitioners reported an increased parental presence, and the authors postulated that it could be due to an increase in the prevalence of family-centered care. A survey of pediatric dentists in Florida reported an increase in parental presence and also reported that they expected the trend to continue to increase in the future. Research by Shroff et al. confirms these observations by pediatric dentists through a survey of parents regarding their desire to be present in the operatory. The survey also addressed the motivation of the parent to remain with the child during treatment. The majority of parents in this study (. percent) desired to stay with their child during any treatment, and. percent desired to be present during a sedation appointment. Two of the main motivations for staying with the child were: ) a belief that the child would be more comfortable with the parent staying in the operatory and ) an overall concern for the child s well-being. In addition, only. percent of parents were comfortable with the practitioner making the decision on whether or not the parent should stay during a sedation appointment. One objective of the present survey was to address the type of preconceived notions and ideas a parent would bring into the discussion with a pediatric dentist about the process of oral conscious sedation. This information would allow the pediatric dentist to have a more appropriate, effective, and efficient discussion with

6 Page of Pediatric Dentistry the parent about the process of sedating his/her child. A byproduct of this more effective discussion would be a more comprehensive and truly informed consent by the parent regarding the procedure proposed. Recently, multiple stories have surfaced in the mainstream media detailing fatalities during pediatric dental appointments which utilized sedation., Therefore, included in this objective was an attempt to understand the effect media coverage (both social media and traditional media) of negative outcomes involving pediatric dental sedations may have had on parental attitudes about sedation. The present survey also attempted to gauge parental acceptance of scenarios that might occur when treating a child with oral conscious sedation, including the use of protective stabilization. A final goal of this study was to elucidate gaps in knowledge or understanding that might exist between the parent s knowledge base and the routine discussion the dentist or dental staff may have with parents regarding sedation. Discovering areas where parental knowledge is lacking or erroneous could help facilitate true and comprehensive informed consent. Informed consent can only be achieved when the parents have appropriate knowledge either derived from external sources or conveyed to the parent by the pediatric dentist and staff. A shift has occurred with regard to informed consent and what is required of the practitioner. Informed consent now includes what a typical or reasonable parent would want to know from a practitioner versus the previous standard of what a reasonable and typical dentist would share. Bross points out that parents have become more informed consumers regarding the healthcare of their children. The standard of care is not static and what is considered reasonable care can change as

7 Page of well. There can be an expectation of zero defect dentistry from parents, consequently setting the standard inappropriately high for the pediatric dentist METHODS Participants were recruited from three private pediatric dental practices and the University Pediatric Dentistry Clinic. Participants included primary caregivers accompanying a child to the dental appointment, and a written survey was administered while parents were in the waiting room. A consent disclosure form was discussed with parents and a copy of the consent disclosure form was given to parents to take home. Exclusion criteria included parents whose primary language was not English and those who could not read and understand written English. This study was approved by the IRB Review Committee (approval -0-XM). The survey consisted of questions or statements with multiple choice type responses. Respondents were given no information or knowledge prior to administration of the survey other than being told to answer the questions to the best of their knowledge and to give response per question. One question pertaining to the type of insurance held by the respondent allowed for multiple responses due to a limited number of respondents having secondary insurance coverage. The exclusion criteria were that the respondents must speak and read English and be a primary caregiver for the patient who had presented to the office that day for treatment. Accordingly, the term parent in this article will apply to any primary caregiver who completed the survey for simplicity. Basic socio-economic and demographic information was collected as well as past sedation experience. The response types were different depending on the

8 Page of Pediatric Dentistry question or statement. Demographic questions gave categorical options while statements about the purpose or process of oral sedation allowed for respondents to strongly agree, agree, disagree, or strongly disagree. Some of the statements allowed for a yes/no response, including I am not sure. Finally, a series of statements was made giving a treatment scenario involving the respondent s child (i.e. he/she sleeps through all dental work or he/she cries and moves a little bit, but the dentist is able to fix the teeth). They were asked to respond yes or no if they were OK with the given scenario. Surveys were collected immediately following their completion. The responses to the multiple choice questions were then transferred from the written forms into a digital spreadsheet for data analysis. Incomplete or incorrectly completed surveys were not included in the data transfer to help preserve data integrity. Data were entered into a spreadsheet (Microsoft Excel, Redmond, WA) and statistics were generated using Statistical Analysis System, SAS, (SAS Institute Inc., Cary, North Carolina). Percentage statistics were generated for all categorical variables. Cross-tabulations and independent Chi-Square statistics were used to examine relationships between categorical variables in the survey. P values less than.0 were considered to be statistically significant. RESULTS A total of surveys were collected from the three different offices in the Mid-South. Of these surveys, were incomplete or incorrectly marked (n=). Respondents indicated their type of insurance as follows:. percent of the surveys were completed by respondents with insurance exclusively through a

9 Page of managed care provider;. percent of the surveyed individuals had some form of private insurance; and. percent indicated they had no insurance. Almost half (. percent) of respondents indicated they had a child who had previously had sedation in a dental office while the other. percent indicated they had no children with previous sedation experience. Respondents indicated their level of education as follows:. percent of respondents did not complete high school while. percent had high school or equivalent as their highest level of education, and. percent of respondents had a college degree with. percent having some form of an advanced or professional degree. Only. percent of respondents were less than years of age. Nearly one third (. percent) were age - while. percent were - years of age. Twenty percent of respondents were over the age of. As stated above, survey respondents were nearly split regarding past pediatric dental sedation experience. Parents with past sedation experience were more likely to view sedation as safe or very safe and were more likely to agree/strongly agree that the use of passive restraint should not be needed, though neither of these findings were statistically significant (Table ). Those with past sedation experience were also less likely to agree that one purpose of sedation was to fix all teeth in one visit. Younger parents were more likely to want to stay with their child during treatment, though the difference was not statistically significant (Table ). Even though older parents were less likely to want to remain with the patient, the vast majority desired to stay with the child. Younger parents also had increased

10 Page of Pediatric Dentistry acceptance of treatment scenarios involving moving and crying by the patient, though not statistically significant. Older parents were more likely to conclude that the child could return to school/daycare the same day as treatment, though the overwhelming majority of parents, regardless of age, selected the next day as an appropriate response. The majority of parents reported not having seen news coverage on pediatric dental sedation; however, when both the youngest and oldest parents saw news coverage, it was likely to be viewed through television coverage. As parental age decreases, it becomes more likely for a parent to report that the sedation is designed to help restore all the teeth at one appointment (Table ). Parents overall hold a fairly favorable view of sedation safety. Most parents found sedation to be safe or very safe (Figure ). In addition to those findings at the safe end of the spectrum, no (0) parents surveyed in this study held the view that sedation was unsafe. Table shows the overall trend of parental acceptance of certain treatment scenarios. A clear trend emerges. As patient activity level increases (ie. struggling and crying), the parental acceptance of the process decreases. Parents appear to be comfortable with their child sleeping during dental sedation but are very uncomfortable with their child showing signs that may be interpreted as anger, fright, or pain. Only a little over half of respondents (. percent) approved of the dentist completing treatment if the child cried and moved some. A little less than half (. percent) found it acceptable for the dentist to stop fixing the teeth if the child cried and moved some.

11 Page of The caretaker s level of education appears to only have a minor bearing on knowledge or opinion about sedation (Table ). As an overall trend, increased education level led to an increase in the desire of the parent to stay with the child during treatment. Increased education level also led to a decreased acceptance of distressed treatment scenarios. Figure highlights the increased level of parental expectations about dental treatment and sedation concerning their child. A vast majority of parents agree that sedation is designed to put their child to sleep during treatment. A majority, though to a lesser degree, also feel that sedation is designed to fix all of the patient s teeth in one visit. Finally, a large majority feel that passive restraint, such as a papoose board, should not be necessary to help control a child s movement if the child has been sedated. Irrespective of demographic profile, this survey reveals parents want to be with their child when they are treated (Figure ). There is somewhat less of a consensus in other knowledge areas when parents are surveyed. Over half of those surveyed either felt that a shot was not needed to numb the [sedated] child s teeth or were unsure. Likewise, parents were unsure about cost. Almost percent of respondents were not sure if any extra expense was involved (Figure ). DISCUSSION Parents, regardless of demographic profile, have reasonable knowledge of some of the purposes and the procedure of dental sedation. The majority of parents consider the next day to be an appropriate time for their child to return to school or day care and believe that dinner the night prior to treatment would be the last solid

12 Page of Pediatric Dentistry food the child should have before the appointment. Fewer than percent assumed that there would be no need for local anesthetic. One caveat to this finding was that over percent of the parents were unsure if a shot would be needed (Figure ). On the other hand, parents appear to misunderstand or lack understanding in several areas. Many parents are under the false impression that oral sedation in the pediatric dental office is designed to render the patient asleep (Figure ). This could correlate to the comfort level that parents have with general anesthesia and being put to sleep. In contrast to the pediatric dentist, many parents view sleep as safer than increased response and activity by their child during treatment. The current study confirms that while pediatric dentists correlate crying and wakefulness to a patent airway and overall safety, many parents view increased activity with concern and disapproval (Table ). It appears advisable that parents are reminded of certain aspects of the sedation process on the day of treatment prior to sedating the child. Many times it has been weeks since the patient was treatment planned for sedation and the consent was signed. Most likely, this also would have been the last time the parent discussed the sedation process with the dentist or staff. A reminder that the child will still have local anesthetic administered could clear up some confusion. This also applies to the child sleeping during the appointment. A quick reminder that the child may fall asleep because of their relaxation level but the sedation is not intended to render them unconscious could be helpful to many parents and their expectations of the day.

13 Page of Many respondents also thought a purpose of sedation was to fix all teeth in one visit. Results in this area could be skewed slightly by the fact that some parents with a child who was previously sedated have had all of the child s dental needs resolved in one visit. This could be due to limited dental needs of the child or a parent confusing general anesthesia with oral sedation. Almost half of the respondents to this survey had a child who experienced a previous sedation. This is above the percentage of patients that dentists report needing sedation, as most (. percent) report using it with roughly less than percent of their patients. However, respondents in this survey were asked if they had experienced sedation with any of their children, not just the child presenting at the current appointment. This could have captured a larger pool of parents with previous sedation experience. Parents are unsure of the financial ramifications of oral sedation, including its expense to them directly, as more than one-third of the survey respondents felt unsure if the sedation would add additional cost. However, insurance coverage could cloud the analysis of this question as many parents surveyed in this study (. percent) participate in a managed care program. In the Mid-South, this program typically eliminates the out of pocket expense for dental treatment and conscious sedation, as can some private insurance providers. Thus, a parent may recognize no cost for sedation, but in fact a fee was associated with the procedure and was charged to the insurance provider. Therefore, a portion of the. percent of parents who stated that there was no additional cost for sedation may be speaking accurately based on their own previous experience.

14 Page of Pediatric Dentistry Accepted treatment in the pediatric dental community has continually evolved in response to our changing world. Some treatment approaches once considered acceptable and common by pediatric dentistry are now taboo. An example would be the elimination of the use of hand over mouth (HOM) behavior guidance. Once taught in many if not all pediatric dental residency programs, HOM is no longer endorsed by the American Academy of Pediatric Dentistry (AAPD). In addition the AAPD adopted a new guideline regarding passive restraint in, highlighting that Frankel in found percent of parents desired to be with their child if a papoose board was used to restrain their child even though 0 percent of the parents understood that the restraint was designed and purposed to protect the child. Passive restraint, via wrap or papoose board, continues to be an unpopular method of advanced behavior guidance. In the present survey,. percent of respondents stated that they agreed or strongly agreed with the statement that the dentist should not have to use a wrap (like a papoose or straps) to help control a child s wiggling or movement if that child had sedation. This aligns with past studies showing similar reservations among parents regarding passive restraint. -, Even among pediatric dentists, less than half report that it is always acceptable for sedated patients. This trend further complicates behavior guidance for precooperative or uncooperative pediatric dental patients. The practitioner is in the unenviable position of having parents who do not want passive restraint, but are also not comfortable with movement by the child during treatment.

15 Page of Another trend confirmed by this survey was increased parental presence in the operatory. Nearly percent of parents expressed desire to stay with their child during sedation. This affirms the responses to the surveys conducted by Shroff et al. and Marcum et al. However, Wells et al., found that only about a quarter of pediatric dentists allowed parents in the operatory during a sedation visit for over percent of their patients. Well over half of pediatric dentists reported allowing parents to be present for less than percent of their patients. Most likely, practitioners prefer parental absence for sedation visits in order to concentrate solely on the child s sedation status and treatment needs. Dentists have reported various reasons for excluding parents from the operatory such as parental presence adds time to the appointment and disrupts the behavior of the child. Despite the feelings of dentists regarding parental presence, parents feel that their child will be comforted by their presence, and they are concerned for their child s well-being. It also appears to ease the anxiety of the parent when they are permitted to remain in the operatory with their child. Casamassimo et al. reported pediatric dentists noting a change in parenting styles on the whole, with the majority of respondents believing the change was for the worse and resulted in poorer child behavior. This behavior is most likely due to poor self-control or selfdiscipline exhibited by an increasing number of children. Also, this behavior can be linked to an increase in the prevalence of permissive parenting. The children of permissive parents also may have an increased incidence of caries and fewer positive initial dental visits. Assuming this trend continues, a higher portion of the practitioner s day will be filled with appointments for children of permissive

16 Page of Pediatric Dentistry parents, and pediatric dentists must adapt to these new challenges. More practitioners have begun to allow parents in the operatory for most procedures, and this trend will most likely continue. Adapting to parental presence in the operatory means improving communication with the parent. Without being properly informed, the parent who is present in the operatory may be surprised by the methods the practitioner is using to treat the child. They may be surprised that the child is not asleep or that the child will still require local anesthesia to complete the procedures. Additionally, parents who may have been exposed to news coverage of a pediatric dental sedation fatality may influence the practitioner to lighten the dose of sedative given to the child. Without fully discussing the threshold at which the parent may wish to abort treatment should the sedation be ineffective, the appointment could lead to increased movement and crying by the child and ultimately to increased parent disapproval. This survey speaks to why this may be the case. Increased sedation dosages, in addition to poly-pharmacy, can render patients less reactive and more manageable. - While this may not always be the case, when it does occur, parents are more agreeable to the process of sedation. And while the lowest effective dose should be the approach of any pediatric dentist performing oral sedations, based on this survey, it is without question that parents are much more comfortable with a sedation appointment where the child is less reactive. The highest ratings were given for the child sleeping during the appointment, which corresponds to an overall increased comfort with sedation and general anesthesia

17 Page of by the parents (Figure ). Importantly, this highlights a lack of awareness by the respondents of some of the safety concerns that can accompany sleep during a sedation appointment. Accordingly, the treatment dosage selected by the pediatric dentist is balanced against both the safety of a given regimen and against that regimen s efficacy in the eyes of the parent. One surprising finding from the survey was that only. percent of respondents reported seeing either internet coverage, television coverage, or both regarding dental sedation. Parents from a younger age demographic were more likely to have seen internet coverage. Less than percent of participants who had seen some form of coverage indicated that they were less likely to choose sedation as a result of what they had seen or read, and. percent of participants indicated they were more likely to choose sedation. This was an unexpected finding for the authors, given the discussion for the study design that revolved around the negative media coverage regarding pediatric fatalities during dental treatment under sedation. A possible explanation for this finding is that parents are inundated with multiple media ads regarding adult sedation dentistry, and the ads promise comfort, relaxation, and decreased anxiety along with a beautiful smile. Moreover, these ads most likely contribute to the predisposing view that sedation is safe, as nearly 0 percent of respondents viewed sedation in the dental office for their child as safe or very safe. While there may have been some bias in the responses due to the setting of the survey exactly 0 participants marked that they viewed sedation as unsafe.

18 Page of Pediatric Dentistry Further study of parental attitudes about conscious sedation and which characteristics of parents affect those attitudes is important for the pediatric dental community. Parents can never be too informed, and the more the pediatric dental community can guide the discussion surrounding sedation, the more properly informed the public will be. It is probably safe to assume that information obtained online will only continue to grow as the world becomes more connected through the internet and social media. Learning the public s concerns and knowledge base about dental sedation allows the practitioner to improve the informed consent process and best address concerns by parents and patients alike. CONCLUSIONS. An overwhelming majority of parents desire to stay with their child during treatment, affirming a shift of parental desires and expectations in the pediatric dental office.. Despite parental demographics parents generally have a good understanding of some sedation protocol including NPO guidelines and returning to school or daycare.. As treatment is rendered in spite of increasingly difficult behavior patterns by the child, parental acceptance of completed treatment falls precipitously.. Parents are generally unaware of news coverage pertaining to dental sedation. Those parents who are aware of adverse news coverage still generally view sedation favorably.. A majority of parents believe that restraints should not be necessary during a pediatric dental sedation appointment.

19 Page of. Parents generally have a favorable opinion of the safety of sedation in a dental office.. A majority of parents have an expectation that sedation should put their child to sleep during the appointment. ACKNOWLEDGMENTS The researchers would like to thank Drs., their staffs, and patients for participation in this survey. REFERENCES. Fuhrer CT, rd, Weddell JA, Sanders BJ, et al. Effect on behavior of dental treatment rendered under conscious sedation and general anesthesia in pediatric patients. Pediatr Dent 0;():-.. Lawrence SM, McTigue DJ, Wilson S, et al. Parental attitudes toward behavior management techniques used in pediatric dentistry. Pediatr Dent ;():-.. Eaton JJ, McTigue DJ, Fields HW, Jr., Beck M. Attitudes of contemporary parents toward behavior management techniques used in pediatric dentistry. Pediatr Dent 0;():-.. Murphy MG, Fields HW, Jr., Machen JB. Parental acceptance of pediatric dentistry behavior management techniques. Pediatr Dent ;():-.

20 Page of Pediatric Dentistry. Wells M, McTigue DJ, Casamassimo PS, Adair S. Gender shifts and effects on behavior guidance. Pediatr Dent ;():-.. Marcum BK, Turner C, Courts FJ. Pediatric dentists' attitudes regarding parental presence during dental procedures. Pediatr Dent ;():-.. Shroff S, Hughes C, Mobley C. Attitudes and preferences of parents about being present in the dental operatory. Pediatr Dent ;():-.. Bradford, Harry. Dental Sedation Responsible For At Least Child Deaths Over Years. The Huffington Post URL: Accessed: (Archived by WebCite at Healy, Michelle. After child surgery deaths, experts discuss the risks. USA Today URL: Accessed: (Archived by WebCite at Bross DC. Managing pediatric dental patients: issues raised by the law and changing views of proper child care. Pediatr Dent 0;():-.. Dosani FZ, Flaitz CM, Whitmire HC, Jr., Vance BJ, Hill JR. Postdischarge events occurring after pediatric sedation for dentistry. Pediatr Dent ;():-.

21 Page of. American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline on Protective Stabilization for Pediatric Dental Patients. Pediatr Dent -; ():... Frankel RI. The Papoose Board and mothers' attitudes following its use. Pediatr Dent ;():-.. Scott S, Garcia-Godoy F. Attitudes of Hispanic parents toward behavior management techniques. ASDC J Dent Child ;():-.. Peretz B, Kharouba J, Blumer S. Pattern of parental acceptance of management techniques used in pediatric dentistry. J Clin Pediatr Dent ;():-.. Bauchner H, Vinci R, Bak S, Pearson C, Corwin MJ. Parents and procedures: a randomized controlled trial. Pediatrics ;():-.. Casamassimo PS, Wilson S, Gross L. Effects of changing U.S. parenting styles on dental practice: perceptions of diplomates of the American Board of Pediatric Dentistry presented to the College of Diplomates of the American Board of Pediatric Dentistry th Annual Session, Atlanta, Ga, Saturday, May, 0. Pediatr Dent 0;():-.. Mauro CF, Harris YR. The influence of maternal child-rearing attitudes and teaching behaviors on preschoolers' delay of gratification. J Genet Psychol 00;():-.. Howenstein J, Kumar A, Casamassimo PS, et al. Correlating parenting styles with child behavior and caries. Pediatr Dent ;():-.

22 Page of Pediatric Dentistry. Peretz B, Kharouba J, Somri M. A comparison of two different dosages of oral midazolam in the same pediatric dental patients. Pediatr Dent ;():-.. Moreira TA, Costa PS, Costa LR, et al. Combined oral midazolam-ketamine better than midazolam alone for sedation of young children: a randomized controlled trial. Int J Paediatr Dent ;():-.. Somri M, Parisinos CA, Kharouba J, et al. Optimising the dose of oral midazolam sedation for dental procedures in children: a prospective, randomised, and controlled study. Int J Paediatr Dent ;():-.. Nathan JE, Vargas KG. Oral midazolam with and without meperidine for management of the difficult young pediatric dental patient: a retrospective study. Pediatr Dent 0;():-.. Musial KM, Wilson S, Preisch J, Weaver J. Comparison of the efficacy of oral midazolam alone versus midazolam and meperidine in the pediatric dental patient. Pediatr Dent 0;():-.

23 Page of Table : Parental opinion of scenarios correlated with previous sedation experience.

24 Page of Pediatric Dentistry Table : Parental opinion of scenarios correlated with parental age.

25 Page of Figure : Parental opinion of the level of safety of conscious sedation for pediatric dentistry.

26 Page of Pediatric Dentistry Table : Parental opinion of scenarios correlated with education level.

27 Page of Table : Parental acceptance of sedation appointment scenarios SCENARIO % PARENTAL ACCEPTANCE n = () Child sleeps throughout.% Child is awake but sleepy.% Child cries and moves some, work completed Child cries and moves some, work aborted Child cries and moves significantly, work completed.%.%.%

28 Page of Pediatric Dentistry Figure : Parental agreement with statements about sedation scenarios 0 0 A B C Strongly Disagree Disagree Agree Strongly Agree --Statement A: I think that one reason for sedation is to put my child to sleep during a dental procedure --Statement B: I think that one reason for sedation is to allow the dentist to fix all of my child s teeth in one visit --Statement C: The dentist should not have to use passive restraint to help control a child s wiggling or movement if that child had sedation.

29 Page of Figure : Parental opinions regarding local anesthetic use during sedation, the cost of sedation, and the preference to remain with the patient A B C Yes No Not Sure --Statement A: I think that my child will need a shot to numb their teeth if they are sedated. --Statement B: If my child needs sedation, it will cost extra money. --Statement C: If my child needs sedation, I would like to stay with him when he gets his teeth fixed.