USING TEMPERAMENT TO PREDICT BEHAVIOUR DURING DENTAL TREATMENT WITH NITROUS OXIDE SEDATION FOR 3- TO 7-YEAR-OLD CHILDREN

Abstract

Nitrous oxide (N2O) sedation is a safe and well-accepted pharmacological behaviour management technique used in paediatric dentistry. While there is information on its effect on dental treatment completion, little is known regarding the predictors of behaviour success. Additionally, there is also no evidence on the patient-reported outcomes of N2O sedation. The primary aim of this prospective cohort study was to examine the association between a child’s temperament and outcomes during the first dental treatment visit with N2O sedation. The secondary aim was to explore the child’s perception to dental treatment with N2O sedation. Seventy-two healthy children between 36 to 95 months of age were enrolled in this study. Temperament was assessed via parental completion of the Child’s Behaviour Questionnaire Short Form. Recruited children received dental treatment with N2O sedation, and their behaviours were assessed by an independent rater using the Venham Behaviour Rating Scale (ranges from “0” i.e., total cooperation to “5” i.e., general protests). At the subsequent visit, both the child and parent were interviewed about the child’s experience with dental treatment with N2O sedation. Planned dental treatment was completed in 84.7% of this study’s sample, and it was not associated with temperament. When considering dental treatment completion with behaviour success, the rate of Venham behaviour success <3 (defined at the midpoint of the Venham Behaviour Rating Scale) was 73.6%, and the rate of Venham behaviour success <1 (defined as total cooperation with no protest behaviour) was 33.3%. The temperament domain of effortful control was associated with the mean overall Venham behaviour viii scores (?=-0.266, p=0.024) and Venham behaviour success <1 (OR=3.506, 95% CI=1.328 to 9.259, p=0.011). Behaviour success, regardless of the cut off employed, was not associated with gender, age, presence of pain, primary dentist, anticipatory guidance and use of audio-visual distraction. Frankl behaviour rating score at the baseline visit was significantly associated with behavioural outcomes of N2O sedation (p<0.001 for overall Venham behaviour score, p<0.001 for Venham behaviour success <3, and p=0.017 for Venham behaviour success <1). A full predictive model (consisting of five items: age, baseline Frankl behaviour rating score, anticipatory guidance, dental procedures performed and whether the child enjoys gentle rhythmic activities) for Venham behaviour success <3 achieved a 79.7% accuracy, 79.6% sensitivity and 80.0% specificity. At the post-treatment interview, majority (82.5%) of the child subjects were able to recall the dental treatment visit with N2O sedation, with most of them (68.4%) reporting to have enjoyed that visit but approximately one-third (36.8%) remembering it as difficult. Dental treatment completion with Venham behaviour success <3 was significantly associated with a child reporting to have enjoyed dental treatment under N2O sedation (p=0.033). In conclusion, this study found that temperament is associated with behavioural outcomes (overall Venham behaviour score and Venham behaviour success <1) during a child’s first dental treatment with N2O sedation, but not treatment outcomes (dental treatment completion). Baseline behaviour was a major predictor of a child’s behaviour during the N2O sedation visit. Also, most children would remember their dental treatment visit with N2O sedation. histological diagnosis of irreversible pulp disease and intact uninflamed pulp respectively in 100% of the teeth evaluated (10 out of 10). The clinical diagnosis of irreversible pulpitis matched the histological diagnosis of irreversible pulp disease for 57% (17 out of 30) of teeth evaluated. The sensitivity and specificity for the clinical diagnosis of irreversible pulpitis were 53% and 73% respectively. For the clinical diagnosis of reversible pulpitis, 83% (25 out of 30) matched the histological diagnosis of reversible pulp disease. The sensitivity and specificity for the clinical diagnosis of reversible pulpitis were 52% and 86% respectively. While the accuracy of the clinical diagnosis of normal pulp and pulp necrosis utilising the 2013 AAE diagnostic criteria falls within an acceptable threshold for a diagnostic test to have appropriate clinical utility, it falls short for reversible and irreversible pulpitis. Existing studies in primary teeth correlating clinical diagnosis of pulp status and histological findings is unclear and have considerable shortcomings due to the use of either outdated or non-validated clinical and histological criteria. This study aimed to evaluate the degree of correlation between the clinical diagnosis of reversible and irreversible pulpitis using the currently accepted 2013 American Association of Endodontists (AAE) classification of pulpal health with histological findings in primary teeth. This study involved 80 primary teeth collected from patients presenting to a tertiary centre over a 9-month period. The teeth were clinically diagnosed as having normal pulp (n=10), reversible pulpitis (n=30), irreversible pulpitis (n=30) and pulp necrosis (n=10) according to the currently accepted 2013 AAE diagnostic criteria. The teeth were histo processed and the pulp tissues were diagnosed histologically as intact uninflamed pulp, reversibly inflamed, irreversible inflamed and necrosis using a combination of the criteria used by Ricucci et al and Seltzer et al.3,14 A statistical grouping to dichotomise the histological findings of pulp inflammation into two groups, reversible pulp disease (inclusive of intact uninflamed pulp and reversibly inflamed) and irreversible pulp disease (inclusive of irreversibly inflamed and necrosis), were carried out not only to ease statistical analysis but also because the clinical management of the teeth within a group were the same. Sensitivity, specificity and predictive values were calculated for normal pulp, reversible pulpitis, irreversible pulpitis and pulp necrosis. The clinical diagnosis of pulp necrosis and normal pulp matched the vii histological diagnosis of irreversible pulp disease and intact uninflamed pulp respectively in 100% of the teeth evaluated (10 out of 10). The clinical diagnosis of irreversible pulpitis matched the histological diagnosis of irreversible pulp disease for 57% (17 out of 30) of teeth evaluated. The sensitivity and specificity for the clinical diagnosis of irreversible pulpitis were 53% and 73% respectively. For the clinical diagnosis of reversible pulpitis, 83% (25 out of 30) matched the histological diagnosis of reversible pulp disease. The sensitivity and specificity for the clinical diagnosis of reversible pulpitis were 52% and 86% respectively. While the accuracy of the clinical diagnosis of normal pulp and pulp necrosis utilising the 2013 AAE diagnostic criteria falls within an acceptable threshold for a diagnostic test to have appropriate clinical utility, it falls short for reversible and irreversible pulpitis.

components of bimaxillary orthognathic surgery treatment planning. Skeletal cephalometry has historically been used but has been found to be unreliable and outcomes poorly correlated with facial esthetics. Despite multiple soft tissue cephalometric analyses proposed, there is no consensus on an analysis to predictably identify the ideal sagittal position of the maxilla. This thesis investigates the simulated esthetic outcomes of skeletal cephalometry based treatment planning versus various soft tissue based cephalometric analyses in the Chinese population of Singapore