Scientific Article Intranasal midazolam better at effecting amnesia after sedation than oral hydroxyzine: a pilot study

Providing amnesia about a surgery is a desired side effect of a medication. This study compares anterograde amnesic effects of midazolam with hydroxyzine in children undergoing dental treatment with those drugs plus nitrous oxide, using a recall test. Thirty ASAI children 24-28 months, were shown a Standard-Binet intelligence scalememory for objects subtest before entering treatment room. Twenty-one randomly determined children received 3.7 mg/kg hydroxyzine 45 min before treatment or 0.2 mg/kg intranasal midazolam in two succeeding appointments, alternatively. Recall in the 30-subject treatment group was 90%. Recall in the 21-subject treatment group was 71% for hydroxyzine and 29%for midazolam. Midazolam was more effective in creating amnesia than hydroxyzine in this study. (Pediatr Dent 18:32-34, 1996) M idazolam as a premedication and sedative in adult patients is well established as more potent, faster acting, and inducing amnesia of a procedure better than diazepam. 1, 2 Its use as a premedication for the conscious sedation of children during dental treatment is not as well described, particularly its amnesic effect, which is of specific interest to the pediatric dentist. 3-1° Past studies employed a simple memory test to evaluate the drug’s amnesic effect including questionnaires, pictures, parents’ and patients’ recall of the visit, and willingness to return for future visits.2,11-13 Patients were shown a picture or a series of pictures before or during treatment and were requested to recall the picture after treatment.14-16 This technique may be reliable in adults or older children, however studies are lacking on whether this test is suitable for detecting amnesia in 2to 4-year-olds. The purpose of this pilot study was to investigate the degree of anterograde amnesia obtained with midazolam compared with hydroxyzine in children undergoing dental treatment under conscious sedation with nitrous oxide by using a recall test. Methods and materials Development of memory recall procedure Thirty subjects between the ages of 24 and 48 months (mean age of 36.4 months) participated in this part of the study. All participants arrived at the dental clinic for a first-time appointment with no previous dental experience. Each child was shown a picture from the StanfordBinet Intelligence Scale Memory for Objects subtest (Level I-K, Items I and 2s, pp 142-44, 150-52. Item book #3, Sattler JM, Hagen EP, Thorndike RL, 4th Ed, The Riverside Publishing Company, 1986) prior to entering the treatment room. The test consists of common objects (e.g., shoe, flower, telephone, etc.) presented one at time by the examiner. The child then chooses the previously presented picture from a larger array of pictures. One randomly chosen picture from two sets of pictures was shown to the child. The child was asked to point to the picture and identify it three times. Children who were not familiar with the picture were asked to repeat the name of the picture following the examiner. Parents were present but asked to refrain from commenting or assisting the child. After examining the child in the treatment room and returning the child to the waiting area, the child was shown an arrangement of five pictures that included the previously shown picture. The child was requested to point to the picture previously shown. Children reluctant to cooperate were coaxed or persuaded to point to the picture with the promise of a reward. Children who did not understand the request, particularly those younger than 3 years, were asked to point to or touch any picture. Assessment of memory in sedated children Twenty-one subjects between the ages of 22 and 48 months (mean age of 34.0 months), participated in the experimental group. An initial screening examination and behavior assessment were performed by a senior pediatric dentist. All participants were in good health (ASA 1), had no previous dental experience, and re32 American Academy of Pediatric Dentistry Pediatric Dentistry18:1, 1996 quired at least two restorative treatment sessions. The patients required sedation for treatment because of a "definitely negative" or "negative" rating according to the Frankl behavior rating scale. 17