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Sedation versus general anaesthesia for provision of dental

treatment in under 18 year olds (Review)

Ashley PF, Williams CECS, Moles DR, Parry J

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library

2012, Issue 11

http://www.thecochranelibrary.com

Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

7DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iSedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

[Intervention Review]

Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds

Paul F Ashley1, Catherine ECS Williams2, David R Moles3 , Jennifer Parry4

1Unit of Paediatric Dentistry, UCL Eastman Dental Institute, London, UK. 2Dept Paediatric Dentistry, Guy’s and St Thomas’ NHS

Foundation Trust, London, UK. 3Oral Health Services Research, Peninsula Dental School, Plymouth, UK. 4 Special Care Dentistry,

Sussex Community Trust, Haywards Heath Health Centre, Haywards Heath, UK

Contact address: Paul F Ashley, Unit of Paediatric Dentistry, UCL Eastman Dental Institute, 256 Grays Inn Road, London, WC1X

8LD, UK. [email protected].

Editorial group: Cochrane Anaesthesia Group.

Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 11, 2012.

Review content assessed as up-to-date: 31 July 2012.

Citation: Ashley PF, Williams CECS, Moles DR, Parry J. Sedation versus general anaesthesia for provision of dental treatment in under

18 year olds. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD006334. DOI: 10.1002/14651858.CD006334.pub3.

A B S T R A C T

Background

A significant proportion of children have caries requiring restorations or extractions, and some of these children will not accept this

treatment under local anaesthetic. Historically this has been managed in children by the use of a general anaesthetic, however use

of sedation may lead to reduced morbidity and cost. The aim of this review is to compare the efficiency of sedation versus general

anaesthesia for the provision of dental treatment for children and adolescents aged under 18 years.This review was originally published

in 2009 and updated in 2012.

Objectives

We evaluated the intra- and postoperative morbidity, effectiveness and cost effectiveness of sedation versus general anaesthesia for the

provision of dental treatment for under 18 year olds.

Search methods

In this updated review we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012,

Issue 7); MEDLINE (Ovid) (1950 to July 2012); EMBASE (Ovid) (1974 to July 2012); System for information on Grey Literature in

Europe (SIGLE) (1980 to October 2008), Latin American & Caribbean Health Sciences Literature (LILACS) (1982 to July 2012), and

ISI Web of Science (1945 to October 2008). The searches were updated to July 2012. The original search was performed in October

2008.

We also carried out handsearching of relevant journals to July 2012. We imposed no language restriction.

Selection criteria

We planned to include randomized controlled clinical trials of sedative agents compared to general anaesthesia in children and adolescents

aged up to 18 years having dental treatment. We excluded complex surgical procedures and pseudo-randomized trials.

Data collection and analysis

Two authors assessed titles and abstracts for inclusion in the review. We recorded information relevant to the objectives and outcome

measures in a specially designed ’data extraction form’.

1Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

mailto:[email protected]

Main results

We identified 15 studies for potential inclusion after searching the available databases and screening the titles and abstracts. We identified

a further study through personal contacts. Following full text retrieval of the studies, we found none to be eligible for inclusion in this

review.

Authors’ conclusions

Randomized controlled studies are required comparing the use of dental general anaesthesia with sedation to quantify differences such

as morbidity and cost.

P L A I N L A N G U A G E S U M M A R Y

Comparing sedation with general anaesthesia to manage children who need to have dental treatment

This updated Cochrane systematic review aimed to look at any evidence comparing sedation with general anaesthesia for the delivery

of dental care to children aged up to 18 years. At present children who are unable to cope with dental care under local anaesthetic

may be given general anaesthesia or sedation, which is dependent on factors such as preference, economic constraints or the local

regulatory framework. There is a suggestion that undertaking this work under sedation might make the experience more comfortable

for the patient and could even be cheaper for the funding body. In our original review we searched the databases until October 2008.

In this updated review we searched the following databases to July 2012, CENTRAL, MEDLINE, EMBASE, LILACS and ISI Web

of Science. Unfortunately the search could not identify any randomized controlled trials on this topic. Therefore we recommend that

these trials be carried out.

B A C K G R O U N D

Description of the condition

It is widely recognized that the level of caries in children of in-

dustrialized nations has dropped substantially over the last few

decades. Unfortunately a significant proportion of these children

still have caries and much of it remains untreated. In the USA,

20% of all two to five year olds had untreated dental caries in 2004

(NCHS 2007). Similarly, of the 39% of five year olds in the UK

who had dental caries in 2006 only 11% of these children had

received any treatment (Nugent 2007). This represents a signifi-

cant problem because if dentine caries are left untreated they will

usually lead to pain and sepsis which can often only be managed

by extraction or extensive restoration of the affected teeth.

The obvious alternative is to provide treatment under local anaes-

thesia; however some children will not be able to accept this.

Barriers to treatment may be dental fear or behaviour manage-

ment problems. Dental fear and behaviour management prob-

lems are closely related phenomena; in one study, 61% of children

with dental fear presented with behaviour management problems

(Klingberg 1995). Estimates of the prevalence of dental fear are

hard to find, however one Swedish study reported 10.5% of chil-

dren with behaviour management problems out of a population

of four to 11 year olds (Klingberg 1994). Dental fear or anxiety is

associated with increased levels of caries (Julihn 2006).

Methods of managing anxiety and behaviour are therefore required

to meet this need. Whilst behavioural techniques that do not in-

volve the use of drugs can play an important part in a child’s man-

agement, many children will still find it difficult to tolerate dental

treatment. In these cases sedation or general anaesthesia could be

considered as a method for reducing anxiety and facilitating the

provision of dental treatment.

Description of the intervention

Sedation or general anaesthesia (GA) are widely used to manage

behaviour and support the provision of dental treatment across

the world. It is unclear, however, if either technique offers advan-

tages over the other. Both carry a risk of mortality (Cote 2000;

Poswillo 1990), albeit small. Both procedures are also associated

with postoperative morbidity (Atan 2004; Cote 2000). Finally,

both procedures require the use of additional facilities including

drugs, equipment and staff and therefore both lead to additional

cost for the service provider and patient.

2Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

How the intervention might work

One of these interventions may be superior to the other in terms

of cost, safety and patient acceptance.

Why it is important to do this review

As the current trend in caries development within young children

suggests that demand for these services is unlikely to disappear,

further information comparing the relative risks and benefits of

GA versus sedation is required. Therefore the aim of this review was

to compare the efficiency of sedation versus GA for the provision

of dental treatment for children and adolescents under 18 years

of age. An understanding of the costs involved in the provision of

GA was an objective of this review. Costs may be affected by how

and where the anaesthetic or sedation is administered.

O B J E C T I V E S

We evaluated the intra- and postoperative morbidity and effective-

ness of sedation versus GA for the provision of dental treatment to

under 18 year olds. If data become available, then we will analyse

the cost effectiveness of the differing interventions. If this is not

the case, then we will obtain crude estimates of cost.

Morbidity can be defined as ’an undesired result or complication’.

For the purposes of this review, intraoperative morbidity refers to

any complications during the procedure which may necessitate

action by the anaesthetist or sedationist, such as respiratory arrest.

Postoperative morbidity refers to undesired results or complica-

tions following the procedure once the patient had been restored

to consciousness and could breathe unaided, such as nausea.

M E T H O D S

Criteria for considering studies for this review

Types of studies

We planned to include randomized controlled clinical trials

(RCTs) (including cluster-randomized trials).

We planned to exclude pseudo-randomized trials.

Types of participants

We planned to include children and adolescents aged up to 18 years

of age. We planned to include children and adolescents having

dental treatment including fillings, removal of the nerve from a

tooth and extraction of a tooth.

We excluded from this study children and adolescents having com-

plex surgical procedures. For the purposes of this review, we de-

fined complex surgical procedures as any procedure where bone

was removed

Types of interventions

Test group

Sedative agents administered via any route by an anaesthetist, den-

tist or other healthcare professional in any setting.

Control group

General anaesthesia administered via any route by an anaesthetist,

dentist or other healthcare professional in any setting.

Types of outcome measures

We planned to measure the following outcomes.

Primary outcomes

1. Mortality (if any)

2. Completion of treatment: yes or no

3. Intraoperative morbidity

4. Postoperative morbidity

Secondary outcomes

1. Cost to the patient

2. Cost of procedure

3. Patient satisfaction

4. Parental satisfaction

Estimation of cost may not be recorded or different methodologies

may be used to calculate this. Therefore in addition to cost data

we also planned to record the following variables, where available:

1. length of patient stay;

2. length of procedure;

3. facilities used;

4. materials used;

5. equipment used;

6. staff required.

We planned the following subgroup analyses:

1. age;

2. dental procedure;

3Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

3. sedative agent;

4. operator providing sedation or anaesthetic (i.e. dentist or

anaesthetist).

Search methods for identification of studies

Electronic searches

In this updated review, we searched the Cochrane Central Register

of Controlled Trials (CENTRAL) (The Cochrane Library 2012,

Issue 7), see Appendix 1; MEDLINE, OvidSP (1950 to July

2012), see Appendix 2; EMBASE, OvidSP (1974 to July 2012),

see Appendix 3; System for information on Grey Literature in

Europe (SIGLE) (1980 to October July 2012); Latin American

& Caribbean Health Sciences Literature (LILACS) (1982 to July

2012), see Appendix 4; ISI web of Science (1945 to July 2012),

see Appendix 5.

Our original search (Ashley 2009) was performed in October

2008.

We developed detailed search strategies for each database. We

based these on the search strategy developed for MEDLINE and

revised them appropriately for each database.

Our search strategy was combined with the subject search in phases

one and two of the Cochrane Handbook for Systematic Reviews of

Interventions (Higgins 2011) and was also run separately.

We also searched the following databases up to July 2012 (free text

search for dent* and sed* and (anaesth* or anesth*)) for additional

relevant trials and references:

• the World Wide Web (Google),

• Community of Science Database,

• ClinicalTrials.gov (http://www.controlled-trials.com/),

• http://www.opengrey.eu/,

• http://www.ifpma.org/clinicaltrials.html.

We cross-checked these with those studies identified already.

We did not impose a language restriction.

Searching other resources

Handsearching

In our original review (Ashley 2009) we handsearched the follow-

ing journals for the period 2000 to 2007. In this updated review

we searched the journals to 20 July 2012:

• American Academy of Pediatric Dentistry;

• Anaesthesia;

• British Dental Journal;

• British Journal of Anaesthesia;

• Dental Update;

• International Journal of Paediatric Dentistry;

• Journal of American Dental Association;

• Journal of Dentistry for Children;

• Pediatric Dentistry.

We checked the reference lists of all eligible trials for additional

studies.

Unpublished studies

We contacted specialists in the field that are known to us for any

unpublished data.

Data collection and analysis

Selection of studies

Two authors (CAWI) and (PA) assessed the titles and abstracts for

inclusion in the review. We selected papers suitable for inclusion

in this review using our selection criteria.

Data extraction and management

We extracted information relevant to the objectives and outcome

measures into a specially designed ’Data Extraction Form’ (Ap-

pendix 6). We resolved any disagreements between authors by dis-

cussion. We were not blinded to the journal of publication or the

authors’ names on the papers.

We planned to collect descriptive data (where available) in addi-

tion to what was already outlined. These data were to be used to

provide contextual information for the main outcomes thus aid-

ing interpretation of results from this review. We have provided

details in Appendix 6.

1. Year study started (if not available, year it was published).

2. Country study was carried out in.

3. Previous treatment of patient.

4. Fasting before the procedure.

5. Use of restraints during the procedure.

6. Level of consciousness throughout the procedure.

7. Monitoring used.

8. Procedure and recovery time.

9. Anxiety before and after treatment.

10. Patient satisfaction/acceptance.

11. Treatment carried out.

Assessment of risk of bias in included studies

We planned to assess the risk of bias using the methodology set out

in the Cochrane Handbook for Systematic Reviews of Interventions

(Higgins 2011). We planned to assess included trials based on the

following criteria.

• Random sequence generation.

• Allocation concealment.

4Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

http://ClinicalTrials.gov

http://www.controlled-trials.com/

http://www.opengrey.eu/

http://www.ifpma.org/clinicaltrials.html

• Blinding, assessed in three groups: patient, operator or

sedationist or anaesthetist, outcome assessor. If the authors state

that a study is double blind then it is assumed that at least the

patient and outcome assessor are blinded.

• Incomplete outcome data.

• Selective reporting.

• Other bias.

We planned to record a description of what was reported to have

happened in the study in sufficient detail to support a judgement

about the risk of bias for each included trial, along with a judge-

ment of low, high or unclear risk of bias.

The criteria for risk of bias judgements regarding allocation con-

cealment are given below, as described in the Cochrane Handbook

for Systematic Reviews of Interventions 5.1.0 (Higgins 2011).

• Low risk of bias: adequate concealment of the allocation

(e.g. sequentially numbered, sealed, opaque envelopes or

centralised or pharmacy-controlled randomization).

• Unclear risk of bias: uncertainty about whether the

allocation was adequately concealed (e.g. where the method of

concealment is not described or not described in sufficient detail

to allow a definite judgement).

• High risk of bias: inadequate allocation concealment (e.g.

investigators knew in advance what the allocated assignment of

the next participant would be).

We planned to undertake a summary assessment of the risk of bias

for the primary outcome (across domains) (Higgins 2011).

Within a study, a summary assessment of low risk of bias will be

given when there is a low risk of bias for all key domains, unclear

risk of bias when there is an unclear risk of bias for one or more

key domains, and high risk of bias when there is a high risk of

bias for one or more key domains. Across studies, a summary

assessment will be rated as low risk of bias when most information

is from studies at low risk of bias, unclear risk of bias when most

information is from studies at low or unclear risk of bias, and high

risk of bias when the proportion of information is from studies at

high risk of bias sufficient to affect the interpretation of the results.

We plan to include all studies meeting the selection criteria in this

review regardless of quality.

Measures of treatment effect

For dichotomous outcomes such as treatment completion it was

planned to calculate risk ratios along with 95% confidence inter-

vals (CI); continuous outcomes would be reported as mean and

standard deviation in each group.

Unit of analysis issues

We plan that the approaches used will be outlined as described

in the Cochrane Handbook for Systematic Reviews of Interventions

5.1.0 (Higgins 2011).

Dealing with missing data

We plan that the approaches used will be outlined as described

in the Cochrane Handbook for Systematic Reviews of Interventions

5.1.0 (Higgins 2011).

Assessment of heterogeneity

We will assess heterogeneity in the results of the trials, where ap-

propriate, by inspection of a graphical display of the results and

by formal tests of heterogeneity.

Assessment of reporting biases

We plan that this will be assessed, where appropriate, by inspection

of funnel plots of the results and formal tests if possible.

Data synthesis

We plan that where either dichotomous outcome variables or con-

tinuous outcome variables with means and standard deviations are

available, these data will be recorded.

A random-effects model is planned where there are more than four

trials in an analysis. The outcome of standardized mean difference

is planned to be used in situations where different scales are used

to measure the same outcome.

Subgroup analysis and investigation of heterogeneity

We propose conducting subgroup analyses for the following

groups, provided sufficient data exist.

• Age: this will be subdivided into three groups, 0 to 5, 6 to

11, 12 to 17 years (as recommended by the British National

Formulary (BNF) when prescribing drugs to children).

• Dental procedure.

• Sedative.

• Operator providing sedation or anaesthetic.

Sensitivity analysis

Sensitivity analysis will be planned a priori to compare the study

results for risk of bias. We will undertake both fixed-effect model

and random-effects model meta-analyses to assess the robustness

of the results.

R E S U L T S

Description of studies

See: Characteristics of excluded studies.

5Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

Results of the search

In Ashley 2009, we originally identified 16 studies for potential

inclusion after searching the available databases and screening the

titles and abstracts (Figure 1). We identified a further one study

through personal contacts. Following full text retrieval of the stud-

ies, we found none to be eligible (see ’Characteristics of excluded

studies’). We identified no further studies in the updated search

(July 2012).

Figure 1. Search results

Included studies

There were no eligible studies (see ’Characteristics of excluded

studies’).

Excluded studies

The studies were not RCTs comparing sedation to GA (see

’Characteristics of excluded studies’).

Risk of bias in included studies

There were no eligible studies (see table ’Characteristics of

excluded studies’).

6Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

Allocation

There were no eligible studies (see ’Characteristics of excluded

studies’).

Blinding

There were no eligible studies (see ’Characteristics of excluded

studies’).

Incomplete outcome data

There were no eligible studies (see ’Characteristics of excluded

studies’).

Selective reporting

There were no eligible studies (see ’Characteristics of excluded

studies’).

Other potential sources of bias

There were no eligible studies (see ’Characteristics of excluded

studies’).

Effects of interventions

There were no eligible studies (see ’Characteristics of excluded

studies’).

D I S C U S S I O N

Summary of main results

We did not find any RCTs comparing general anaesthesia (GA) to

sedation for the provision of dental care in children. There were

a few publications comparing any form of sedation to GA using

methodologies such as case control studies.

Overall completeness and applicability of evidence

The sedation method most commonly compared to GA was in-

halation sedation with nitrous oxide and oxygen (IHS). Stud-

ies looking at this were reviewed by Lyratzopoulos and Blain

(Lyratzopoulos 2003). They looked at the evidence from seven

case series and felt that results from these studies were suggestive

that IHS could prevent the need for GA in many children and may

result in better outcomes with regard to morbidity. Obviously this

conclusion should be interpreted with caution given the quality

of the studies included. What that review did highlight was some

of the problems with designing adequate RCTs to look at this is-

sue. Chief amongst these was the issue of the relative effectiveness

of the sedative technique to the GA. This is particularly relevant

when considering techniques such as IHS. They noted that the

children selected for the IHS treatment were non-representative

of the population requiring GA treatment and that IHS was un-

likely to ever be suitable for young children requiring extractions

of multiple diseased teeth.

If treatment with sedation is to be an effective alternative to GA,

then it needs to allow provision of similar levels of dental treatment

and should be suitable for younger children, as they are more likely

to require GA. Given that available evidence suggests that IHS is

unsuitable for providing this (Lyratzopoulos 2003), are there any

other methods of sedation that could be appropriate? Averley et al

(Averley 2004) demonstrated that sedation with inhaled sevoflu-

rane and intravenous (IV) midazolam can be used to successfully

provide dental treatment in a group of children and adolescents

who might otherwise need GA. Again, though, no direct com-

parisons with GA were made. In a subsequent paper this team

also looked at the cost of this alternative approach compared to

GA (Jameson 2007). They concluded that GA was 46.6% more

expensive than an ’advanced’ conscious sedation approach; how-

ever the data were not based on direct comparisons. Whilst one

episode of dental care under sedation might be cheaper than a

similar episode under GA, it is not clear if a similar amount of

treatment can be delivered under sedation. Dental treatment un-

der sedation may require several visits to complete the treatment;

this is not the case for dental treatment delivered under GA. In

addition, sedation may be unsuccessful on some occasions thereby

necessitating a subsequent GA.

So how should an RCT to compare sedation and GA be designed?

Obviously the first consideration is the type of sedative technique

to be used. This needs to allow provision of extractions and restora-

tions on children and adolescents comparable to what is achievable

under a general anaesthetic. Importantly it also needs to allow the

placement of restorations that will last. GA facilitates the ’ideal’

placement of restorative materials as the patient will not move

throughout the procedure. This may not be the case in a sedated

patient.

Outcome variables must also be chosen carefully. Mortality or seri-

ous morbidity following sedation or GA are rare, and sample sizes

required to objectively look at these would probably be too large to

allow a study to be run. However, less serious measures of morbid-

ity (such as nausea) are common and occur frequently enough to

be used as sensible outcome variables. Cost is another important

outcome to consider. Sedation may well be cheaper per visit than

GA, but how many sedation visits will be required to complete the

treatment that will almost certainly be completed in one GA visit?

Treatment quality must be assessed. As described above, sedation

may not provide the optimum situation for restoration placement.

7Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

Finally, patient satisfaction and quality of life are also important

considerations.

Quality of the evidence

No RCTs were available to assess.

Potential biases in the review process

No RCTs were available to assess.

Agreements and disagreements with other studies or reviews

No RCTs were available to assess.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

We did not find any RCTs comparing general anaesthesia and se-

dation for children and adolescents undergoing dental treatment.

We are therefore unable to make recommendations about the use

of sedation or general anaesthesia for the provision of dental treat-

ment in under 18 year olds.

Implications for research

Carefully designed and well run RCTs are required to provide a

comparison of sedation and GA for the provision of dental treat-

ment in children and adolescents.

A C K N O W L E D G E M E N T S

We would like to thank Dr Mathew Zacharias (content editor);

Robert F Seal; Mona Nasser; Raphael Freitas de Souza; Sandra

White and Nai Ming Lai (peer reviewers) and Anne Peticolas

(Cochrane Consumer Network) for their help and editorial advice

during the preparation of the original review (Ashley 2009).

R E F E R E N C E S

References to studies excluded from this review

Arch 2001 {published data only}

Arch LM, Humphris GM, Lee GT. Children choosing

between general anaesthesia or inhalation sedation

for dental extractions: the effect on dental anxiety.

International Journal of Paediatric Dentistry 2001;11(1):

41–8. [PUBMED: 11309872]

Bettelli 1990 {published data only}

Bettelli G, Giulietti MP, Bitelli G, Iseppi D, Caproni G,

Saetti A, et al.Handicapped patients. General anesthesia

or sedation? [Pazienti handicappati. Anestesia generale

o sedazione?]. Dental Cadmos 1990;58(4):78–83.

[PUBMED: 2144246]

Blain 1998 {published data only}

Blain KM, Hill FJ. The use of inhalation sedation and local

anaesthesia as an alternative to general anaesthesia for dental

extractions in children. British Dental Journal 1998;184:

608–11. [PUBMED: 9682563]

Camm 1987 {published data only}

Camm JH, Mourino AP, Cobb EJ, Doyle TE. Behavioral

changes of children undergoing dental treatment using

sedation versus general anesthesia. Pediatric Dentistry 1987;

9:111–7. [PUBMED: 3475679]

Chalazonitis 1968 {published data only}

Chalazonitis J, Chalazonitis A. Dental treatment for

children under sedation and general anesthesia [He

odontiatrike therapeia ton paidon te boetheia kateunastikon

kai anaisthetikon pharmakon]. Odontiatriki 1968;4:

199–201. [PUBMED: 4239654]

Crawford 1990 {published data only}

Crawford AN. The use of nitrous oxide-oxygen inhalation

sedation with local anaesthesia as an alternative to general

anaesthesia for dental extractions in children. British Dental

Journal 1990;168(10):395–8. [PUBMED: 2346696]

Crock 2003 {published data only}

Crock C, Olsson C, Phillips R, Chalkiadis G, Sawyer S,

Ashley D, et al.General anaesthesia or conscious sedation

for painful procedures in childhood cancer: The family’s

perspective. Archives of Disease in Childhood 2003;88(3):

253–7. [PUBMED: 12598395]

Fabre 2004 {published data only}

Fabre S, Vaysse F, Carpentier C, Kern D, Fourcade O. Is

premixed 50% nitrous oxide and oxygen an alternative to

general anaesthesia for dental care in children? [Le MEOPA

est–il une alternative a l’anesthésie générale pour les soins

dentaires chez l’enfant ?]. Annales Francaises d’Anesthesie et

de Reanimation 2004;23(1):72–3. [PUBMED: 14980330]

Foley 2008 {published data only}

Foley J. Paediatric minor oral surgical procedures under

inhalation sedation and general anaesthetic: a comparison

of variety and duration of treatment. European Archives

of Paediatric Dentistry 2008;9(1):46–50. [PUBMED:

18328239]

8Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

Girdler 1997 {published data only}

Girdler NM. General anaesthesia versus inhalational

sedation for children’s exodontia [General anaesthesia versus

inhalational sedation for children’s exodontia]. Anaesthesia

1997;52(1):89. [PUBMED: 9014562]

Lee 2000 {published data only}

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pediatric dental patients using general anesthesia versus

conscious sedation. Pediatric Dentistry 2000;22(1):27–32.

[PUBMED: 11724224]

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Loyola-Rodriguez JP, Aguilera-Morelos AA, Santos-Diaz

MA, Zavala-Alonso V, Davila-Perez C, Olvera-Delgado H,

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Shaw AJ, Meechan JG, Kilpatrick NM, Welbury RR. The

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Paediatric Dentistry 1996;6(1):7–11. [PUBMED: 8695592]

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referred for general anaesthesia. British Dental Journal 1998;

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[PUBMED: 10800240]

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general anaesthesia. British Dental Journal 2004;197(9):

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McCloskey C. Adverse sedation events in pediatrics: a

critical incident analysis of contributing factors. Pediatrics

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Jameson K, Averley PA, Shackley P, Steele J. A comparison

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[PUBMED: 17632457]

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dental fear: cause related factors and clinical effects.

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Lyratzopoulos G, Blain KM. Inhalation sedation with

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References to other published versions of this review

9Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

Ashley 2009

Ashley PF, Williams CE, Moles DR, Parry J. Sedation versus

general anaesthesia for provision of dental treatment in under

18 year olds. Cochrane Database of Systematic Reviews 2009,

Issue 1. [DOI: 10.1002/14651858.CD006334.pub2] ∗ Indicates the major publication for the study

10Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Arch 2001 Structured interview measuring anxiety with child at pre-treatment and at one week follow up set in a primary

healthcare centre. Children aged 9 to15 years were provided information about IHS and GA and then invited

to choose which method they preferred. Children having IHS were less anxious postoperatively than children

who had GA

Reason for exclusion: Not an RCT.

Bettelli 1990 Review/opinion article.

Reason for exclusion: Not an RCT.

Blain 1998 Patients (mean age 7.6 years) referred in for management of caries under GA were given IHS instead. Outcomes

included treatment completion and relative cost. 83% of patients referred in for a GA were managed with IHS

Reason for exclusion: Not an RCT

Camm 1987 Case control study with three groups of children (age range 23 to 71 months). Children had dental treatment

either with GA, sedation or just LA and postoperative behavioural change was assessed. Authors reported that

GA and sedation produced postoperative behavioural change (both positive and negative). Children who had

treatment under LA had no change in behaviour after the procedure

Reason for exclusion: Not an RCT.

Chalazonitis 1968 Review/opinion article.

Reason for exclusion: Not an RCT.

Crawford 1990 Patients referred in for GA extractions were offered IHS instead. Of those who consented to take part, 87%

completed treatment under IHS

Reason for exclusion: Not an RCT.

Crock 2003 Retrospective analysis of the experiences of children with cancer who had either had GA or sedation for bone

marrow aspirates/lumbar punctures. GA regime showed much lower levels of pain and distress than the sedation

Reason for exclusion: Not an RCT. Not dental treatment.

Fabre 2004 Reason for exclusion: Letter. Not an RCT.

Foley 2008 Prospective analysis of children attending for paediatric minor oral surgical procedures under sedation or GA.

The majority of procedures were carried out under GA

Reason for exclusion: Not an RCT.

Girdler 1997 Reason for exclusion: Letter. Not an RCT.

Lee 2000 Cost analysis looking at the cost of GA in a group of 22 children and estimating the cost of conscious sedation

in the same group. The GA group was more cost effective if it was likely the conscious sedation group would

require more than three visits to complete treatment

Reason for exclusion: Not an RCT.

11Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

(Continued)

Loyola 2004 Case report describing the use of either sedation or GA to manage a group of children and young adults with

cerebral palsy requiring dental treatment. Majority of children (77%) treated with GA

Reason for exclusion: Not an RCT.

Milnes 2003 Description of a “cost-effective” intravenous sedation program being used in a pediatric dental practice in

Kelowna, British Columbia

Reason for exclusion: Not an RCT.

Shaw 1996 Patients referred in for extractions (n =133, 4 to 17 years age) were offered treatment under IHS rather than

GA. 90% were successfully managed with most of those who had had GA previously expressing a preference for

IHS

Reason for exclusion: Not an RCT.

Shaw 1998 Reason for exclusion: Letter. Not an RCT.

Shepherd 2000 Paediatric patients referred in for orthodontic extractions were offered IHS or GA (n = 101); 35 chose GA with

the remainder choosing IHS. Postoperative morbidity in the IHS group was significantly lower than in the GA

group

Reason for exclusion: Not an RCT.

GA: General anaesthesia

IHS: Inhalation sedation with nitrous oxide and oxygen

LA: Local anaesthesia

RCT: Randomized controlled trial

12Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

D A T A A N D A N A L Y S E S

This review has no analyses.

W H A T ’ S N E W

Last assessed as up-to-date: 31 July 2012.

Date Event Description

25 September 2012 New citation required but conclusions have not

changed

We found no new or excluded studies. We updated

the methods to conform to Higgins 2011.

25 September 2012 New search has been performed In the previously published version of our review

(Ashley 2009) we searched the databases until Oc-

tober 2008. In this updated version we searched the

databases to July 2012

H I S T O R Y

Protocol first published: Issue 1, 2007

Review first published: Issue 1, 2009

Date Event Description

8 January 2008 Feedback has been incorporated Substantive amendment

C O N T R I B U T I O N S O F A U T H O R S

Paul F Ashley (PA), Catherine ECS Williams (CAWI), David R Moles (DM), Jennifer Parry (JP)

Conceiving the review: PA, CAWI, JP

Co-ordinating the review: CAWI

Undertaking manual searches: CAWI, PA

Screening search results: AS, CAWI, JP

Organizing retrieval of papers: CAWI, PA

Screening retrieved papers against inclusion criteria: CAWI, PA

Appraising quality of papers: CAWI, PA

Abstracting data from papers: AS, CAWI, JP

Writing to authors of papers for additional information: CAWI, PA

Providing additional data about papers: CAWI, PA

13Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

Obtaining and screening data on unpublished studies: CAWI

Data management for the review: CAWI

Entering data into Review Manager (RevMan 5.1): CAWI

RevMan statistical data: CAWI, DM

Other statistical analysis not using RevMan: DM

Double entry of data: (data entered by person one:CAWI; data entered by person two: PA)

Interpretation of data: CAWI, PA, JP

Statistical inferences: DM

Writing the review: CAWI, AS

Securing funding for the review: N/A

Performing previous work that was the foundation of the present study: PA

Guarantor for the review (one author): CAWI

Person responsible for reading and checking review before submission: JP

D E C L A R A T I O N S O F I N T E R E S T

Paul F Ashley: none known

Catherine ECS Williams: none known

David R Moles: none known

Jennifer Parry: none known

S O U R C E S O F S U P P O R T

Internal sources

• Eastman Dental Institute, UK.

External sources

• No sources of support supplied

14Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)

I N D E X T E R M S

Medical Subject Headings (MeSH)

Anesthesia, Dental [∗methods]; Anesthesia, General [∗methods]; Dental Care for Children [∗methods]; Hypnotics and Sedatives

[∗therapeutic use]

MeSH check words

Adolescent; Child; Humans

15Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds (Review)