Mowafy YN, Wahba NA, Gho Neim TM, Mahmoud GM. Efficacy of buccal versus intranasal route of administration of midazolam spray in behavior management of preschool dental patients. Quintessence Int. 2021 Jul 8;0(0):0. doi: 10.3290/j.qi.b1702197. Epub ahead of print. PMID: 34235908.

Abstract
Objective: To assess the efficacy of aerosolized midazolam, introduced through buccal versus intranasal mucosa in managing uncooperative children undergoing dental treatment.

Method and materials: A crossover randomized controlled clinical trial included 36 children aged 3 to 5 years, rated I or II according to the Frankl scale and ASA I or II. Each child fulfilled the requirement of having a dental condition that needed treatment in two dental settings. They were randomly assigned to one of two groups; either buccal or intranasal aerosolized midazolam was administered at the first visit. The alternate route was implemented with a 1-week washout period in the second visit. Drug acceptance and time until optimum sedation were measured. Crying, sleeping, head resistance, and child overall behavior were assessed using modified Houpt scale.

Results: In total, 34 patients (95 %) were drowsy on optimum sedation. There was a statistically higher acceptance of buccal midazolam (P < .001). Onset of optimum sedation was more rapid for the intranasal group, with a mean of 15.50 ± 4.226 minutes (P < .001), while in the buccal group the mean was 22.97 ± 4.582 minutes. No statistical differences were recorded between the two groups in all behavior rating scales, except for crying where the intranasal group was statistically higher (P = .010). Regarding the overall behavior, there was no significant difference recorded between the two groups (P = .204).

Conclusion: Aerosolized buccal midazolam was more tolerated by the patients. However, intranasal aerosolized midazolam had a more rapid onset of sedation. Both buccal and intranasal administrations of aerosolized midazolam are safe and effective.

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Sado-Filho J, Corrêa-Faria P, Viana KA, Mendes FM, Mason KP, Costa LR, Costa PS. Intranasal Dexmedetomidine Compared to a Combination of Intranasal Dexmedetomidine with Ketamine for Sedation of Children Requiring Dental Treatment: A Randomized Clinical Trial. J Clin Med. 2021 Jun 27;10(13):2840. doi: 10.3390/jcm10132840. PMID: 34199001; PMCID: PMC8269392.

Abstract
Outpatient pediatric sedation is challenging. This study aimed to test intranasal dexmedetomidine efficacy as a single drug or combined with ketamine (DK) to sedate children undergoing dental treatment. Children < 7 years were randomized into dexmedetomidine 2 mcg/kg and ketamine 1 mg/kg (DK) or dexmedetomidine 2.5 mcg/kg (D) groups. Videos from the dental sedation allowed the systematic assessment of children’s behavior (primary outcome) according to the Ohio State University Behavioral Rating Scale (OSUBRS). Secondary outcomes were parental and dentist satisfaction, adverse events, and recovery time. The data were analyzed descriptively and through regression models. Participants were 88 children (44 per group; 50 boys). The duration of quiet behavior (OSUBRS) was higher than 50% (DK mean 58.4 [standard deviation 38.1]; D 55.2 [39.1]; p = 0.225). Parents (DK 78.0 [32.2]; D 72.7 [35.1]; p = 0.203) and dentists (KD 62.7 [41.0]; D 62.8 [40.1]; p = 0.339) were overall satisfied. Adverse events occurred in 16 cases (DK n = 10, 62.5%; D n= 6, 37.5%; p = 0.104) and were minor. The median recovery time in the DK group was 1.3 times greater than in group D (p < 0.05). Intranasal sedation with dexmedetomidine alone is equally efficacious and satisfactory for pediatric sedation with fewer adverse events and faster recovery than the DK combination.

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Shaat MA, Bakry NS, Elshafie AM, Talaat DM. Intranasal versus sublingual route of dexmedetomidine sedation in paediatric dentistry: A randomized controlled clinical trial. Int J Paediatr Dent. 2021 Jun 8. doi: 10.1111/ipd.12848. Epub ahead of print. PMID: 34101918.

Abstract
Background: Many children experience dental anxiety during dental treatment. Conscious sedation is used to alleviate anxiety and enhance a child’s cooperation.

Aim: This study aimed to compare the efficacy of intranasal versus sublingual dexmedetomidine.

Design: Forty-two healthy, uncooperative children participated in the study. They were divided randomly into two groups: In the first visit, Group I received intranasal dexmedetomidine and group II received sublingual dexmedetomidine, whereas at the second visit, the alternate route was implemented in a crossover design. The child’s acceptance of drug administration method was assessed using a 4-point rating scale. Time until optimum sedation was measured. Anxiety during local anesthesia administration was scored using Venham’s rating scale. Postoperative response was recorded through Vernon et al’s questionnaire.

Results: The Modified Vernon et al questionnaire that was answered by the parents 24 hours after the dental visit through the phone showed that there was no negative effect on postoperative behavior of children.

Conclusions: Both routes prevented the increase in anxiety scores equally during local anesthesia and do not have negative effect on postoperative behavior of children. However, the sublingual route showed better acceptance with longer onset time of action than the intranasal route.

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