ABSTRACT Objective: To evaluate the behaviour and stress of children undergoing restorative treatment with and without sedation. Material and Methods: Participants were 14 healthy children aged between 2.5 and 6 years and with a history of dental behavioural management problems. In the dental treatment visit, the child was treated with non-pharmacological techniques, and in the second, moderate sedation was added. The child received the same procedure performed by a paediatric dentist in both visits: composite resin restoration using local anaesthesia and rubber dam isolation. In both visits, saliva was collected at the children's arrival at the dental clinic, during local anaesthesia and at the end of treatment. The visits were filmed for later analysis of behaviour according to the Ohio State University Behavioural Rating Scale. Results: About 78.5% of children improved their behaviour from the first to the second visit. The salivary cortisol curve of the first visit was maintained in the second visit for 21.4% of children but varied in the remaining participants. Conclusion: Most children presented better behaviour and less stress when sedation was added to non-pharmacological techniques during dental care.

Abstract: The aim of this cross-sectional study was to evaluate the impact of dental caries and sociodemographic factors on the oral health-related quality of life (OHRQoL) of children with dental behavior management problems (DBMP) and their families. One hundred and thirty-four dyads of caregivers and children participated. The impact of OHRQoL was assessed using the Brazilian version of the Early Childhood Oral Health Impact Scale (ECOHIS). Socioeconomic variables were obtained from an interview. Dental caries was assessed using the dmft index. The total B-ECOHIS score was categorized as low, medium, or high impact, and its association with the independent variables was determined based on bivariate tests and a multivariate model. The median score for B-ECOHIS was 13 (range: 1–40). The negative impact was reflected mainly by complaints of oral/dental pain, difficulty in eating and parental guilt. The number of teeth with caries was significantly higher among children who experienced a high negative impact on OHRQoL (mean 9.2 [standard deviation 3.5]; p = 0.003) than those who had a low negative impact (7.0 [3.3]). The final adjusted model showed that dental caries remained independently associated with poor OHRQoL (b = 0.100; x2 Wald 4.205; p = 0.040). A greater impact on OHRQoL was experienced by children with DBMP and greater caries experience.

Abstract: There is a lack of evidence on the correlation between salivary biomarkers and subjective measures of dental fear and anxiety in children. This systematic review aimed to retrieve the scientific evidence comparing the results of dental anxiety measured by salivary biomarkers with patient-reported outcomes in pediatric dental setting. The PECOS was as follows: population: pediatric patients aged ≤ 18 years; exposure: patient-reported outcome measures, such as scales and/or questionnaires; comparator: salivary biomarkers; outcome: anxiety, fear, phobia or stress during dental treatment; study design: observational studies or controlled trials. Electronic searches were conducted in PubMed, Scopus, Web of Science, and Ovid databases. Studies that compared scales/questionnaires and salivary biomarkers for the evaluation of dental anxiety, fear, and stress in children/adolescents during dental treatment were included. Certainty of evidence was assessed with GRADE. Risk of bias of the included studies was assessed with the Cochrane tool or the University of Adelaide tool. From the 314 studies identified, eight were included. Participants’ age ranged from three to 13 years. The most used salivary biomarkers and instruments were cortisol and the Dental Subscale of the Children's Fear Survey Schedule, respectively. Most studies showed a weak correlation between objective and subjective measures. The main issues regarding bias were on allocation concealment, blinding of assessors, follow up, and exposure assessment. Certainty of evidence was low/very low. Evidence of salivary biomarkers and patient-reported outcome measures to investigate anxiety, fear and stress in children during in the dental environment is limited. There was no correlation between subjective and objective measures in almost all included studies.

Abstract Objective: To translate and culturally adapt the Modified Child Dental Anxiety Scale - Faces (MCDASf) into Brazilian Portuguese. Material and Methods: The MCDASf consists of eight questions about anxiety toward dental procedures that are answered on a five-point Likert scale ranging from “not worried” (1 point) to “very worried” (5 points). The answers correspond to a scale of face drawings ranging from extremely negative to extremely positive. The process consisted of initial translation, back-translation, expert committee review, and pretesting. Results: The first revised version was applied to 32 children aged 5 to 12 years, 16 from the city of Governador Valadares, Brazil (southeastern region) and 16 from the city of Pelotas, Brazil (southern region). In the first pretest, Item 5 was misunderstood by 6.25% of children in the southern region; Item 6 by 6.25% in both regions; Items 7 and 8 by 87.5% and 100% of those from the southeastern region, respectively, and by 12.5% and 25% of those from the southern region, respectively. Items 7 and 8 were modified by the expert committee, and the second revised version was applied to 32 children, 16 from each region. The only misunderstood items were 4 and 5, both by a 7-year-old boy in Governador Valadares. Conclusion: The Brazilian Portuguese version of the MCDASf was well understood by the sample of children.

Abstract The aim of the study was to investigate the association between psychosocial factors and perception of caregivers about the dental health of their preschool children. A cross-sectional analysis was performed with 146 caregiver-child dyads attended at Pediatric Dentistry school clinics in Goiânia, Midwest Brazil. Data were collected through a structured interview and a questionnaire with the caregivers and the children’s dental records. The study outcome was caregivers’ perception of children’s dental health (positive or negative). The independent psychosocial variables were religiosity (Duke University Religion Index - DUREL) and Sense of Coherence (Antonovsky’s SOC-13 scale). Sociodemographic data and oral health-related variables were also collected as covariates. Bivariate analysis (Pearson’s chi-square, T-test, and Mann-Whitney) and Poisson regression with robust variance were performed. The prevalence of negative perception was 54.8%. In bivariate analysis, negative perception was associated with caries experience and report of dental pain at any time in the child’s life. In the adjusted regression model, prevalence of caregivers with negative perception of their children’s dental health was 1.38 times higher in the group with low organizational religiosity (PR = 1.38; 95%CI 1.05–1.81) and 2.35 times higher in the group of children with high caries experience (PR = 2.35; 95%CI 1.54–3.60). In conclusion, religiosity was associated with caregivers’ perception of dental health of their preschool children undergoing treatment in specialized dental clinics, regardless of their caries experience.

Abstract This randomized parallel-group control trial tested the efficacy of distraction using audiovisual eyeglasses (AVE) during dental procedures [NCT03902158]. Forty-four 6–9 year-old children with low/moderate anxiety and who needed restorative treatment or exodontia of the primary molars were randomly allocated into two groups: the AVE (experimental) and the conventional behavior management techniques (control) groups. Motion sensors were used to measure the participants’ body movements. Dental visits were video recorded, and their pain levels and behavior were assessed using the Faces, Legs, Activity, Cry, and Consolability Behavioral Pain Assessment Scale and the Venham Behavioral Scale, respectively. Anxiety was assessed via heart rate measurements. After treatment, the children scored their pain using the Faces Pain Scale. Mann-Whitney U and chi-square tests were used to compare the groups. The mean score on the behavioral scale was 0.59 in the experimental group and 0.72 in the control group under local anesthesia (p = 0.73). During the procedure, the mean score was 0.41 in the experimental group and 1.32 in the control group (p = 0.07). The mean heart rate was similar in both groups (p = 0.47), but a significant increase during treatment was observed in the control group. There was no difference between the groups in terms of pain, behavior, and self-reported pain scores (p = 0.08). Children aged 6-7 who used the AVE had fewer wrist movements (435.6) than that of children in the control group (1170.4) (p = 0.04). The AVE achieved similar results to the basic behavior management techniques, with good acceptance by the children.

Abstract The aim of this cross-sectional study was to investigate factors associated with dental anxiety in children treated under moderate sedation. Prior to treatment, each child’s dental anxiety was evaluated using the modified Venham Picture Test (VPT). Interviews were also conducted with parents/guardians to gather information on the child’s dental anxiety (Corah’s Dental Anxiety Scale [DAS]), age and sex, shyness or anxiety in the presence of strangers, and dental history, as well as socioeconomic factors. All the children were sedated, and had at least one tooth restored using the atraumatic restorative treatment technique. Child behavior was assessed using the Frankl scale. Data analysis involved descriptive statistics and bivariate tests. The median VPT score was 2.0 (range: 0 to 8). Children who were shy in the presence of strangers (yes: median 2.0 [0-8]; no: 0.5 [0-4]; p = 0.018), and those with negative behavior during dental care (negative: 3.0 [0-8]; positive: 1.0 [0-8]; p = 0.014) had greater anxiety. The child’s dental anxiety was associated with the mother’s education level (≤ 8 years: 4 [2-7]; > 8 years: 1 [0-8]; p = 0.016). The dental anxiety of children treated under sedation is associated with negative behavior, shyness, and the mother’s education level.

Abstract Physicians and dentists usually make clinical decisions and recommendations without a clear understanding of the meaning of the numbers regarding the accuracy of diagnostic tests and the efficacy of treatments. This critical review aimed to identify problems in the communication of diagnostic test accuracy and treatment benefits and to suggest strategies to improve risk communication in these contexts. Most clinical decisions are taken under uncertainty. Health professionals cannot predict the outcome in one individual patient. This uncertainty invites these professionals to make decisions based on heuristics, which gives rise to several cognitive biases. Cognitive biases are automatic and unconscious, so how is it possible to mitigate their undesirable effects on risk interpretation in the context of clinical practice? Some forms of risk communication reinforce cognitive bias, while others weaken them. Maybe one of the most difficult obstacles to overcome is the difficulty to think with numbers. This difficulty probably arises from a mismatch of ancestral adaptations of the brain having to deal with modern environments, which are quite different from the ancestral ones. There are two quite common, but bad, forms of risk communication: the conditional probability and the relative risk reduction or efficacy. People, including physicians and dentists, are confused with this kind of information. The main methods discovered so far to facilitate a clearer understanding are to emphasize the base rates of the events and to use absolute numbers, that is to use natural frequencies, instead of percentages and conditional probabilities.

Resumo Pouco se sabe sobre o impacto de um delineamento cruzado nos desfechos de ensaios clínicos randomizados voltados ao comportamento de crianças durante tratamento odontológico. Este estudo objetivou avaliar o efeito da sequência de administração do sedativo, da droga em si e da idade dos participantes no comportamento de crianças que receberam duas consultas odontológicas consecutivas. Dezoito crianças saudáveis não colaboradoras, 2-5 anos de idade, foram randomizadas em dois grupos: G1 - 1,0 mg/kg midazolam oral (primeira sessão) e placebo oral (segunda sessão); G2 - placebo (primeira) e 1,0 mg/kg midazolam oral (segunda). Um observador treinado avaliou o comportamento infantil. Os dados foram analisados por ANOVA de três fatores (alfa=0,05). Midazolam [média(DP); 71,7%(16,5)] e placebo [48,6%(33,1)] resultaram em mais comportamento não cooperativo quando administrados na primeira sessão comparado com a segunda (p=0,001). Com o uso do placebo, crianças de 2-3 anos de idade exibiram mais comportamento não cooperativo [G1 54,9%(36,2); G2 80,5%(8,3)] que as de 4-5 anos de idade (p=0,04). Além disso, a porcentagem de redução do comportamento não cooperativo foi maior em crianças mais velhas em G1 (76,2%) e em crianças mais novas em G2 (32,9%). Considerando a avaliação do comportamento infantil sob sedação, a primeira sessão odontológica influenciou a segunda visita. Os resultados deste estudo confirmam a especulação de que o delineamento cruzado é inadequado para avaliar o comportamento odontológico relacionado à ansiedade/comportamento infantil; os resultados dos ensaios cruzados de sedação odontológica devem ser tratados com extrema cautela.

Abstract Crossover studies continue to be published in spite of warnings about their inherent risks in relation to behavioral outcomes. This study took the opportunity of access to secondary data analysis in order to demonstrate the impact of a crossover design on the outcomes of randomized clinical trials aimed at the behavior of children during dental treatment. We evaluated the effect of the sequence of sedative administration, the sedative and the participant’s age on the behavior of children undergoing two sequential dental visits. Eighteen uncooperative healthy young children were equally randomly assigned to: (G1) 1.0 mg/kg oral midazolam (first session) and oral placebo (second session); (G2) oral placebo (first) and 1.0 mg/kg oral midazolam (second). One trained observer assessed children’s behavior. Data were analyzed by three-way mixed ANOVA. Both midazolam [mean(SD); 71.7%(16.5)] and placebo [48.6%(33.1)] produced more struggling behavior when they were administered in the first session compared to the second one (p=0.001). For the placebo, children aged 2-3 years exhibited more struggling behavior [G1 54.9%(36.2); G2 80.5%(8.3)] than those aged 4-5 years (p=0.04). Also, the reduction of percentage of struggling behavior was higher in G1 for older children (76.2%) and in G2 for younger children (32.9%). There were significant interactions between drug and sequence of administration, and between drug and age. The results of our study confirm the conventional wisdom that crossover study design is inappropriate to evaluate children’s behavior/anxiety related-dental treatment under sedation and the results of crossover studies of dental sedation should be treated with extreme caution.

RESUMO Objetivo: No Brasil, não há escala que avalie a catastrofização dos pais sobre a dor das crianças. O objetivo deste estudo foi traduzir e adaptar transculturalmente o Pain Catastrophizing Scale-Parents para a língua portuguesa do Brasil e avaliar preliminarmente as propriedades psicométricas de pais/outros parentes de crianças com e sem dor de dente. Métodos: Foi realizado um estudo transversal com 237 pais/outros parentes de 237 crianças. A adaptação transcultural da escala para o português brasileiro foi feita conforme a abordagem universalista. Para avaliar a confiabilidade e a validade da escala, os pais/outros parentes fizeram um relato sobre a dor de dente da criança e preencheram as versões brasileiras da Escala de Catastrofização da Dor-Pais e o Questionário de Desconforto Dentário. Resultados: Houve equivalência semântica com a versão original após pequenas modificações. O alfa de Cronbach para os 13 itens da escala foi 0,83 e os respectivos coeficientes de correlação intraclasse do teste-reteste variaram de 0,63 a 0,97. Os escores obtidos na Escala de Catastrofização da Dor-Pais e no Questionário de Desconforto Dentário apresentaram baixa correlação (rho=0,25; p<0,001). O escore total da Escala de Catastrofização da Dor-Pais diferiu significativamente (p<0,001) em crianças com dor de dente à noite (mediana: 30,0; percentil 25-75: 25,0-35,5) quando comparado com o daquelas sem dor de dente (25,5; 20,0-31,0). Conclusões: A versão brasileira da Escala de Catastrofização da Dor-Pais apresentou características aceitáveis nesta avaliação preliminar e pode ser utilizada no Brasil tanto na prática clínica quanto em pesquisas.

ABSTRACT Objective: In Brazil, there is no scale to assess parental catastrophizing about their child’s pain. This study aimed to translate and cross-culturally adapt the Pain Catastrophizing Scale-Parents to the Brazilian Portuguese language, as well as to preliminarily evaluate its psychometric properties among parents/guardians of children with and without a toothache. Methods: A cross-sectional study was conducted with 237 parents/other relatives of 237 children. Across-cultural adaptation of the scale into Brazilian Portuguese was carried out according to the universalistic approach. To assess the reliability and validity of the scale, parents/other relatives reported on the child’s toothache and filled out the Brazilian versions of the Pain Catastrophizing Scale-Parents and the Dental Discomfort Questionnaire. Results: There was semantic equivalence with the original version after minor modifications. TheCronbach’s alpha for the 13 items of the scale was 0.83, and the respective test-retest intraclass correlation coefficients ranged from 0.63 to 0.97. The scores obtained from the Pain Catastrophizing Scale-Parents and the Dental Discomfort Questionnaire had a low correlation (rho=0.25; p<0.001). Thetotal score of the Pain Catastrophizing Scale-Parents differed significantly (p<0.001) in children with a toothache at night (median: 3.0, 25-75 percentile: 25.0-35.5) compared to those who did not have a toothache at night (25.5; 20.0-31.0). Conclusions: The Brazilian version of the Pain Catastrophizing Scale-Parents was acceptable in this preliminary evaluation and can be used in Brazilian clinical and research practice.

ABSTRACT OBJECTIVE To investigate the impact of dental pain on daily performances among five-year-old Brazilian children. METHODS The study used data of 7,280 five-year-old children participating in the 2010 Brazilian Oral Health Survey (SBBrasil 2010 Project). Children were clinically examined and their parents or carers were interviewed at their homes. The outcome was the prevalence of the oral impacts on daily performance, and the explanatory variable was dental pain in the last six months. Other independent variables were children’s gender and skin color/race, family income, household overcrowding, and caries experience (dmft). Rao-Scott test and Poisson regression for complex samples were carried out. RESULTS The prevalence of impacts on daily performances was 26.1% (95%CI 22.3–30.2). Significant associations were found between the outcome and pain, caries experience, and sociodemographic variables. After adjusting for the independent variables, only pain and caries remained significant. Impacts on daily performances were more frequent among children with pain (PR = 1.14, 95%CI 1.06–1.23) compared to those without pain. Children with low dmft (PR = 1.90, 95%CI 1.39–2.60) and those with high dmft (PR = 3.53, 95%CI 2.78–4.49) had a higher prevalence of impact than those with no caries experience. CONCLUSIONS Dental pain and caries had strong negative impacts on the five-year-old children’s daily performances regardless of their demographic and socioeconomic characteristics.

ABSTRACT OBJECTIVE To investigate the impact of dental pain on daily performances among five-year-old Brazilian children. METHODS The study used data of 7,280 five-year-old children participating in the 2010 Brazilian Oral Health Survey (SBBrasil 2010 Project). Children were clinically examined and their parents or carers were interviewed at their homes. The outcome was the prevalence of the oral impacts on daily performance, and the explanatory variable was dental pain in the last six months. Other independent variables were children’s gender and skin color/race, family income, household overcrowding, and caries experience (dmft). Rao-Scott test and Poisson regression for complex samples were carried out. RESULTS The prevalence of impacts on daily performances was 26.1% (95%CI 22.3–30.2). Significant associations were found between the outcome and pain, caries experience, and sociodemographic variables. After adjusting for the independent variables, only pain and caries remained significant. Impacts on daily performances were more frequent among children with pain (PR = 1.14, 95%CI 1.06–1.23) compared to those without pain. Children with low dmft (PR = 1.90, 95%CI 1.39–2.60) and those with high dmft (PR = 3.53, 95%CI 2.78–4.49) had a higher prevalence of impact than those with no caries experience. CONCLUSIONS Dental pain and caries had strong negative impacts on the five-year-old children’s daily performances regardless of their demographic and socioeconomic characteristics.

Resumo Introdução Pouco se sabe sobre os fatores associados à dor das crianças no tratamento odontológico sob sedação consciente. Objetivo Verificar a associação entre as características pré-operatórias e a dor durante o tratamento odontopediátrico sob sedação. Material e método Este estudo exploratório foi realizado com 27 crianças submetidas a tratamento restaurador sob sedação. As informações sobre idade, sexo e experiência de tratamento odontológico prévio da criança foram obtidas por meio de entrevista aos pais. A condição bucal, determinada a partir da presença de cárie dentária, foi verificada por meio do índice ceo-d. A dor foi avaliada por análise dos vídeos dos tratamentos, por dois examinadores previamente calibrados, utilizando-se os itens “pernas”, “atividade” e “choro” da escala observacional “Face, pernas, atividade, consolabilidade e choro” (FLACC). Os dados foram analisados por meio de testes bivariados. Resultado A maioria das crianças (n=14; 51,8%) não teve dor durante o tratamento odontológico sob sedação. Entre as demais crianças, observaram-se escores de dor baixos ou moderados (mediana 1,1; mínimo 0-3,8). Os escores FLACC não diferiram conforme sexo (P=0,38), experiência prévia de tratamento odontológico (P=0,32) e história de anestesia local (P=0,96). Os escores FLACC não se correlacionaram significativamente com idade (Spearman rho= -0,08; P=0,67) e ceo-d (Spearman rho= -0,04, P=0,84). Conclusão: Neste grupo de crianças, a dor durante tratamento odontológico sob sedação foi pouco observada, de baixa intensidade e não se associou a idade, sexo, condição bucal e experiência odontológica anterior.

Abstract Introduction Little is known about the factors associated with the pain of children in dental treatment under conscious sedation. Objective To investigate the association between preoperative characteristics and pain during pediatric dental treatment under sedation. Material and method This exploratory study was conducted with 27 children in restorative treatment under sedation. Information on age, sex and experience of the children with previous dental treatment was obtained through interviews with parents. Oral health status, determined from the presence of dental caries, was verified using the dmf-t index. Pain was assessed by analyzing videos of the dental treatments by two previously calibrated examiners, using the items “legs”, “activity” and “crying” of the observational scale “face, legs, activity, consolability and crying” (FLACC). Data were analyzed using bivariate tests. Result Most of the children (n=14, 51.8%) had no pain during dental treatment under sedation. Among the other children, lower or moderate pain scores (median 1.1; minimum 0 to 3.8) were observed. The FLACC scores did not vary according to sex (P=0.38), previous experience with dental treatment (P=0.32) and history with local anesthesia (P=0.96). The FLACC scores did not correlate significantly with age (Spearman rho= -0.08, P=0.67) and dmf-t (Spearman rho= -0.04, P=0.84). Conclusion In this group of children, pain during dental treatment under sedation was of low frequency and intensity and did not associate with age, sex, oral condition and previous dental experience.

Abstract There is little evidence on the long-term effects of pharmacological management in children undergoing dental treatment. This study aimed to assess children’s behavior in consecutive dental sessions following oral rehabilitation using different pharmacological regimens for behavioral control. Participants were preschoolers who were previously treated for caries under one of the following: no sedative, oral sedation with midazolam, oral sedation with midazolam/ketamine, or general anesthesia. The children’s behavior in the follow-up sessions was assessed using the Ohio State University Behavioral Rating Scale (OSUBRS); higher scores represented less cooperative behavior (range 5–20). Follow-up assessments were conducted on 50 children under four years old for up to 29 months. Data were analyzed by the Friedman/Wilcoxon tests and Cox regression model. OSUBRS mean (standard deviation) scores for the whole sample decreased from 11.9 (5.4) before treatment to 6.8 (3.2) at the final recall session (p < 0.001). Moderate sedation with midazolam (OR 2.9, 95%CI 1.2–6.9) or midazolam/ketamine (OR 4.3, 95%CI 1.6–11.4) improved children’s future behavior. The general anesthesia group (n = 4) had a small sample size and the results should be considered with caution. Although invasive dental treatment negatively affected the child’s behavior in the dental chair, they became more cooperative over time. Moderately sedated children showed better prospective behavior than those in the non-sedation group.

OBJETIVO: Sedação moderada tem limites no gerenciamento do comportamento infantil. A literatura existente carece de estudos sobre as percepções dos pais a cerca do tema. Este estudo objetivou compreender a percepção das mães sobre sedação após o tratamento dentário de suas crianças sob sedação. MÉTODOS: Doze mães e uma madrinha de crianças de 1.3-8.4 anos, com comportamento definitivamente negativo na cadeira odontológica, que tiveram tratamento odontológico sob sedação oral, foram entrevistadas em profundidade segundo um roteiro semi-estruturado. As respostas foram analisadas usando o método de análise de conteúdo temático e abordagem dedutiva. Foram abordados dois temas gerais: "lado bom" e "lado ruim" da sedação odontopediátrica. RESULTADOS: Análise das entrevistas transcritas indicou que as participantes percebem a sedação odontopediátrica de acordo com duas categorias: "o lado bom" e a "o lado ruim". O lado bom incluiu vantagens do procedimento (por exemplo, segurança, gerenciamento eficaz do comportamento), suporte e conclusão do tratamento odontológico inicialmente planejado. O lado ruim foi relacionado às limitações da sedação moderada (quando a criança continuou lutando) e sua própria ansiedade durante o procedimento. CONCLUSÃO: Apesar de seu próprio estresse, as mães estavam satisfeitas com este método farmacológico de gestão de comportamento.

OBJECTIVE: Moderate sedation has limits in managing children's behavior. Existing literature lacks insight into parental perceptions about the topic. This study aimed to understand mothers' perceptions concerning sedation after their children undergone dental treatment under sedation. METHODS: Twelve mothers and one godmother of 1.3-8.4 year-old children with definitely negative behavior in the dental chair, who had dental treatment under oral sedation, were in depth interviewed according to a semi-structured guide. Responses were analysed using a thematic content method and deductive approach. Two general themes were addressed: "good facet" and "poor facet" of pediatric dental sedation. RESULTS: Analysis of interview transcripts indicated that participants perceived pediatric dental sedation according to two main analytical categories: the "good facet" and the "poor facet". The good facet included advantages of the procedure (e.g. safety, effective behavior management), rapport and completion of the treatment that was initially planned. The poor facet related to limitations of moderate sedation (when child kept struggling) and their own anxiety during the procedure. CONCLUSION: Despite their own stress, mothers were satisfied with this pharmacological method of behavior management.