Premedication in Pedodontics Attitudes and Agents

PEDIATRICDENTISTRY/Copyright ~) 1979 by The American Academyof Pedodontics/ Vol. 1, No. 4 / Printed in U.S.A.

David L. King, D.D.S., Ph.D. William C. Berlocher, D.D.S.

Abstract a dentist should find it necessary to resort to premedicating children to obtain their cooperation. Garfin The goals of premedicationin children’s dentistry are to feels that the routine use of sedatives and tranquiliz- allay excessive apprehensionand to prevent resistance to treatment efforts. With judicious use, premedicatingagents ers may rbflect a "decreased interest in the care and are a valuable and necessary adjunct for the pedodontis~. treatment of the complete child," and Olsen proposes Whenintegrated with proper psychological approaches, that dentists examine their motives to see if they em- premedicationmay enable the anxious child to accept his ploy premedication as a "crutch." Both of these au- first dental experiences without undueemotional turmoil thors emphasize that when faced with a potential or it mayoften allow outpatient treatment of very young management problem, proper psychological ap- "precooperative" children wherethe only alternative might proaches by the dentist will obviate the need for drugs be hospitalization and general anesthesia. Prudent employ- in most instances. MacGregorbelieves the dentist who ment of drugs [or behavior managementis dependent on resorts to premedication or general anesthesia may the training, experience, and iudgementof the operator. actually be treating his own fears and admitting his A regimen of premedicant drugs and dosages is presented inability to manage children. which may serve as base line guidance [or more successful 7 managementof the difficult child patient. In a similar vein, Chambers, a psychologist, decries dentists’ use of premedication in children because it Literature Review eliminates the possibility of the child’s learning to manage his anxiety. Instead, the child is introduced Premedication, Pros and Cons to an unhealthy method of coping with a difficult ,Jones 1 places dentists into one of three categories situation in much the same manner that a drug addict with respect to the views they hold on premedication: or alcoholic learns to react. He also feels physical re- straint is preferred to premedication because it has 1. Those who use premedication rarely and only in potentially less damaging consequences to the child. exceptional cases. However, Fisher, 8 another psychologist, regards any 2. Those whofavor routine use in all patients. use of force by the dentist as an approach which is al- 3. Those who find premedication valuable in behav- ways contraindicated. ior problems. There are a number of authors who are proponents Two recent surveys of pedodontists have indicated of routine premedication for children. Stewart9 feels that approximately 85% use behavior modifying drugs this approach is iustified and necessary because "In with3 some frequency, and that about 15% never do.2, children experiencing perhaps their first dental visit, In both studies, questionnaire design did not exclude apprehension may be acute and damaging." He also the possible use of nitrous oxide-oxygen by those who states that emotional stress on the operator will be re- reported they never use drugs. It is not unlikely that duced. some dentists in this category have found nitrous ox- Kracke1° advocates the routine use of heavy com- ide an effective substitute for drug premedication. bination premedication in order that a child’s total Garfin, 40lsen,5 and MacGregor6 have presented dental treatment may be accomplished in one visit. opinions which suggest there are few occasions when He believes that this practice avoids the multiple emotional upsets and peiorative behavior which can re- Accepted August 6, 1979 sult from a series of appointments.

PEDIATRICDENTISTRY Vol. 1, No. 4 251 Corbett 11 has pointed out that under the best of nitrous oxide sedation, the reasoning being that the conditions, dentistry is not inherently pleasant for the child must be perceptually aware to fully benefit patient and that it is incumbent upon the practitioner fromz3 the learning potential of the situation.7, to use all the aids at his disposal, including premedi- Hawes~4 disagrees with this concept and comments cation, to allay the physical and emotional discomfort that it is doubtful whether an apprehensive child who of the patient. He believes -that the advantages of should have had premedication learns anything of premedication should not be reserved solely for the value while treatment is being performed. handicapped or recalcitrant child, but should be ap- Levitas ~5 and Chambers7 have implied that pre- plied to ease the first dental experiences of the nor- medication is at best a temporary solution to anxiety mal child as well. -that it only serves to postpone the inevitable con- Lampshire1-° classifies the behavior of child patients frontation the patient will have with his fears about in a spectrum from tense cooperative to hyperemotive dentistry when premedication is stopped. But Lamp- and maintains that premedication can be of benefit to shire26, 27 has found it unusual to have to continue pre- all. Dudley13 concurs, implying that overt resistance medication for more than three or four successive ap- by the child to treatment is not the only indication for pointments and notes that the dosage may be reduced premedication. He reasons that the outwardly coop- with each visit. Therefore, he considers premedication erative but emotionally anxious child who leaves the as an aid in establishing confidence and security in a appointment wet with perspiration deserves equal fearful patient after which it is no longer needed. consideration. Shapiro14 has recognized this type of Album, Davies, and Gelmon,28 and Chambiras-~9 also child, saying "The absence of crying or opposition characterize premedication as a temporary adjunct mean little . . . there are manychildren who react to and not an indefinite substitute for proper psychologi- threatening situations by becoming mute and pas- cal adjustment. They feel it can be used to enhance sive," and further that "this type of child mayundergo and reinforce the dentist’s initial attempts at rapport a severe neurotic storm a day or two later." with a difficult patient and that the dentist who ex- In addition to those proponents of premedication pends the effort to become skillfull at premedication already mentioned, several others also have defended is less likely to avoid treatment of children. their rationale by warning of the adverse psychological consequences a dental experience might hold for Premedicating Agents the emotionally labile child. Lang, in Album,16 Most authors seem to agree that inappropriate be- Ruble,lr and Kope118support the concept that a child havior on the part of the child patient is usually the may suffer "psychic trauma" with lasting conse- overt manifestation of an anxiety state. Depending quences as a result of anxiety about dental treatment. on the degree of anxiety and the child’s ability to Lewis19 assumes no position on the value of premedi- cope with it, this behavior may .range in a spectrum cation but believes that subjective fears of dental pro- from reluctant cooperation to violent physical resis- cedures may arouse castration anxiety in boys or be tance. Successful premedication aims at controlling or experienced as a form of sexual assault in girls. Crox- diminishing anxiety, thereby effecting behavior which ten, 20 however, refutes the idea that the dental exper- will facilitate treatment procedures. 17 That premedi- ience has the potential of being a psychologically cation is as muchan art as a science is reflected by traumatic experience for the child and points out that the many different drugs or combinations of drugs this essentially Freudian concept is neither substanti- which have been proposed by various authors. In gen- ated by research nor widely supported by psycholo- eral though, most commonly used agents may be gists. Edelston21 also flatly denies that serious or long grouped within the broad pharmaceutical categories lasting psychological effects can arise from an unfa- of hypnotics, anti-anxiety agents, and narcotics. vorable dental experience, even in a fundamentally The hypnotic class of drugs, when used in appro- anxious or insecure child. priate dosages, produces sedative effects through a McDermott,~’2 a psychiatrist, states that for the depressant action on the sensory cortex. For example, young child, the dental appointment "has far reaching chloral hydrate and the short acting barbiturates, sec- implications for personality growth." He abjures the obarbital and pentobarbital are employed quite often experience "which has been made as non-threatening for premedication in dentistry. Harris 3° believes the and "painless’ as possible, an emotionally sterile ex- barbiturates in particular are valuable for this pur- perience which does not harm, but neither does it pose noting that they sedate quickly with a high fre- promote personality development." Thus, he views quency of success and a very low frequency of un- dentistry for the child as providing an opportunity for desirable effects. Anderson31 has found chloral hy- emotional maturation. Others have used this concept drate to be an effective and safe premedicant when as an argument against use of drug premedication or used in larger dosages. Robbins~2 reports success us-

PRENtEDICATION AI-rlTUDES AND AGENTS 252 King and Bet|ocher ing it either alone or in combination with prometha- duction of a certain amount of amnesia. ~ In accom- zine. He mentions that chloral hydrate has acquired plishing this sedation, diazepam has little effect on an undeservedly bad reputation from its use as a com- blood34 pressure and respiration. ponent of "knockout drops" and also from erroneous Promethazine, although not classified as an anti- reports that it was a circulatory depressant. His clin- anxiety drug, has been characterized by Sadove and ical study involved children whose ages ranged from Fryez~ as producing a state of quiescence with little 22 months to six years. The children in the experi- or no sign of respiratory or cardiovascular depres- mental groups received either 900 mg of chloral hy- sion. Jones~ has noted that it is remarkably free of drate alone or 450 mg of chloral hydrate and 25 mg serious side effects, and that in addition to its value of promethazine. in controlling apprehension, it is also useful for its Dudley13 feels pentobarbital offers many advan- anti-inflammatory and anti-histaminic properties. Mc- tages as a premedicant for children but adds that too Donaldz6 indicates that promethazine alone is useful often dentists invite failure by prescribing an insuf- for calming anxious patients but not particularly ef- ficient dosage. For an oral dose, it is suggested that fective in the defiant child. Dudley13 and Green- 1.5 to 2.0 mg/lb be administered one hour before wald37 emphasize that for maximumeffectiveness, the appointment. In the case of an extremely excit- tranquilizing drugs should be taken for at least one able child, the usual 2.0 mg/lb limit maybe safely in- or two days prior to a dental appointment. creased since there is an extremely wide margin of Several investigators have reported on the efficacy safety with pentobarbital. Dudley believes the para- of combining promethazine with other drugs. Kope118 doxical excitatory effect seen infrequently with barbi- has found that children may "break through" the qui- turates is of little consequence and not a valid excuse escence produced by promethazine when pain is ex- to avoid using these drugs. Whenthis untoward reac- perienced and for this reason he administers meperi- tion does occur, it usually happens shortly after ad- dine for its analgesic effect. Promethazine is given the ministration and gives way to normal sedative action night before and one hour before the appointment in by appointment time. doses ranging from 12.5 to 25 mg depending .on the The anti-anxiety drugs seem to hold promise as ef- child’s age. Meperidine is given also, one hour before fective psychotherapeutic agents in dentistry, but their the appointment, in age-determined doses from 12.5 usefulness has not been evaluated as extensively as to 50 mg. the hypnotics and narcotics. Most are relatively new The narcotic analgesic, morphine, has been em- drugs which are said to produce "psychic sedation" or ployed in dentistry for premedicating purposes, but "quiescence," but their pharmacodynamicsare still ob- recently the newer synthetic narcotics seem to offer scure. Of the manyagents in this category, two have advantages which make them better choices. 17 Mep- emerged as popular choices for premedication pur- eridine (Demerol) and alphaprodine (Nisentil) poses. They are hydroxyzine as either the hydrochlor- been mentioned most often as useful and effective ide (Atarax), or pamoic salt suspension (Vistaril), narcotics for premedication. Their value in behavior and diazepam (Valium). control lies not so muchin their analgesic properties Stewart 9 investigated the effects of hydroxyzine as in the production of a euphoric state in t~he patient. clinically and felt that it reduced preoperative anxiety It is for this reason that the non-narcot.ic analgesics by producing a state of subdued emotional responses such as propoxyphene and ethopheptazine citrate without the loss of mental alertness. He believed it to have little or no application in behavior management be most effective when used in coniunction with problems. 1~ In addition to euphoric .and analgesic nitrous oxide-oxygen sedation. As initial dosages, he properties, the synthetic narcotics also possess some suggested 10 mg for children under four and 20 mg sedative properties and tend to poter~tiate the action for those four and older, to be given 45 minutes prior of sedatives taken concurrently. ~8 An antisialogogue to the appointment. No controls were used in evalu- effect has also been reported as a desirable side effect ating the effectiveness of this regimen. A 97g success of~7 meperidine. rate in managementis claimed but judgement criteria Corbett ~1 has proposed alphaprodine as a premedi- were not given. Hawes~4 has commented that many cant for children. He administers 6 mg of the drug dentists who use no premedication might well claim and 1.25 mg of promethazine via a submucosal in- a similar success rate. injection. The promethazine in addition to potentiat- Diazepam (Valium) seems to offer-promise in the ing the rather small dose of alphaprodine, exerts an pharmocotherapeutic approach to behavior manage- antiemetic action to counteract the moderate fre- ment. The action of diazepam affects the limbic sys- quency of nausea and vomiting brought about by the tem, altering the experience and transmission of emo- narcotic. A maior disadvantage of alphaprodine is res- tions. This results in the reduction of tension and pro- piratory depression 4o and although there are effec-

PEDIATRICDENTISTRY Vol.1, No.4 253 tive antagonists available to counteract it, this serious ployed by the dentist. Stewart 9 has claimed routine side effect makes it unattractive to many dentists. A premeclication with hydroxyzine will result in a great- synergistic depressant effect on respiration occurs er percentage of children who will willingly accept when alphaprodine is combined with barbiturates the nitrous oxide nosepiece. The possible advantages and for this reason combinations of these drugs are of combining nitrous oxide-oxygen sedation with contraindicated.41 other forms of premedication have not been adequate- Meperidine, although possessing less potent anal- ly evaluated. gesic and euphoric properties than alphaprodine, 4"~ is much less likely to produce respiratory depression or emesis. 4z Aduss, Bane and Lang~4 stated that it was Discussion the most commonly used premedicative analgesic at General Considerations the time of their writing and a recent survey of pedo- The province of the dentist is concern for the oral dontists confirmed its continued popularity by a wide health of his patients. He has the responsibility of margin over the next most frequently used analgesic, providing care in a safe, sympathetic and effective ~ alphaprodine. manner. Few people can accept dental treatment Nitrous Oxide-OxygenSedation without at least a mild degree of anxiety and this is Within the past several years, it has become evi- particularly true of children. In our profession, we dent that many dentists have found nitrous oxide- have admitted universally the value of local anesthesia oxygen sedation to be an effective agent in the man- for obtunding pain. But we have shown some reti- agement~ of the child patient. Wright and McAulay sents a behavior problem in dental treatment visits reported that 44~ of pedodontists in their survey were accept dental treatment. The iudicious use of pre- using nitrous oxide in their practices and an addi- medicating drugs cannot make them substitutes for tional 12~ had plans to use it in the near future. Forty- kindness, patience and understanding on the part of seven percent of those using it at the time of the sur- the dentist. Rather, their use indicates genuine con- vey claimed they found applications for it in at least cern for the well-being of the patient. half of their patients. For 7~ of those polled, nitrous Perhaps the psychological implications of the child’s oxide was the sole agent used for out-patient child dental treatment with or without premedication have behavior management. been at best over-emphasized and misinterpreted. It Sorenson and Roth4~. have summarized the advan- has never been demonstrated convincingly that brief, tages nitrous oxide has over premedication with other infrequent treatment visits will have profound and pharmaceutical agents. Rapidity of onset, accurate lasting effects on the personality of a child in either quantitative control, and minimal recovery time are a positive or negative sense. We should appreciate mentioned. Also, inhalation administration is more of- also that the extreme reactions to the dental experi- ten acceptable to the child and parent than oral, par- ence evidenced by some children may be due to in- enteral, or rectal methods of sedation. Another maior fluences quite beyond our abilities to manage without reason for nitrous oxide’s popularity with pedodontists premedication or without compromising the thor- undoubtedly is the relative safety of this agent. oughness or quality of treatment. The child who pre- Langa,4~ a leading advocate of inhalation analgesia, sents a behavior problem in dental treatment visits has pointed out the absence of serious untoward ef- maydisplay similar reactions in other stress situations, fects of nitrous oxide when it is used in appropriate and well-intentioned attempts by the dentist using analgesic concentration. purely psychological approaches frequently will be A special application of nitrous oxide-oxygen is sug- unrewarded. gested by Moller47 in the managementof certain hand- Some opponents of premedication seem to regard icapped children. In addition to the sedating and anxiety and discomfort as part of the human condi- analgesic effects, nitrous oxide is able to de6rease the tion-admittedly unpleasant but inevitable experi- muscular spasticity and uncoordinated movements of ences which are to be borne stoically and not miti- the cerebral palsied child, and thus make outpatient gated by artificial means. Others argue that percep- dental care possible in manyinstances. tion dulling sedatives deprive children of an oppor- Selden~8 has commentedthat nitrous oxide sedation tunity for emotional maturation, because stress, a sup- is a valuable adiunct in treating most children but posed prerequisite to character development, is di- that it is not always an equivalent substitute for other minished. The clinician might well be confused by forms of premedication. Some degree of cooperation the various claims of authors, notably those outside is required initially from the child for it to be effective the dental profession, who credit him with the po- and success is rare if any force or coercion is era- tential of effecting psychic trauma or personality

PREMEDICATIONATTITUDES AND AGENTS 254 Kingand Berlocher growth or "an emotionally sterile experience" during TABLE2. Hydroxyzine(Hcl or Pamoate) treatment of young patients. The child in need of dental treatment presents a challenge to successful management for the practi- Administration: Oral Usual Indication: 1) mild to moderateapprehension tioner. The apprehensive adult is able to deal with 2) may be combined with nitrous his fears by rationalization or by frankly discussing oxide for extremeapprehension his anxieties with the dentist who may suggest premedication or general anesthesia. In pediatric den- Weight(Ibs) Dose (mg) tistry, the onus of deciding whether or not to em- 25-45 25-50 ploy premeditation or to resort to general anesthesia 45-85 50-75 rests almost entirely with the dentist who will act on 85 + 50-100 the basis of his training., judgement, and experience. The dentist who uses premedication is not necessarily "taking the easy way out." After the essential get-ac- quainted appointment, he must attempt accurately to TABLE3. Diazepam(Valium) predict a child’s reaction to future definitive dental procedures and if, in his iudgement, premedication is in order, he is faced with the responsibility of choos- Administration.: Oral ing proper drugs and dosages. The successful use of "Usual Indication: extreme apprehension premedicating agents requires consideration and Weight(Ibs) Dose (mg)* skill and is by no means a facile, automatic method 25-45 2-3 mgx 3 of behavior management. Properly used, premedicant 45-85 2-5 mgx 3 drugs always must be integrated with other accepted 85-1- 2-10 mgx 3 management techniques. *For morningappointment: Drug should be givenafter dinner, at bedtime,and 1 hourbefore dental appointment. For afternoonappointment: Drug should be given at bedtime, Premedication Guidelines uponarising, and1 hourbefore dental appointment. The following tabular guidelines to premedicant usage have been adopte~l by the faculty of the Pedi- atric Dentistry Department, The University of Texas TABLE4. Chloral Hydrate(NOCTEC) Health Science Center at San Antonio. The tables deal with average appropriate dosages of specific drugs, used alone or in combination. It is recognized Administration: oral that many different agents and combinations not men- Usual indication: Young"pre-cooperative" (3 years or tioned here, have been proposed as effective premed- under) i~ants; however, selection has been consciously lim- Weight(Ibs) Dose (mg) ited so that experience and familiarity may be gained 25-45 750-1250 with a few established and representative examples. 45-85 1000-1500 85+ 1250

TABLE1. PromethazineHcl (Phenergan) TABLE5. SodiumPentobarbital (Nembutal) Administration: Oral Usual Indication: 1) mild to moderateapprehension Administration: I.M. 2) may be combined with nitrous Usual Indication: Young"pre-cooperative" (3 years or oxide for extreme apprehension under) Weight(Ibs) Dose(mg) Weight(Ibs) Dose (mg) 25-45 25-37.5 25-45 70-120 45-85 25-50 45-85 100-150 85+ 50 85+ 150

PEDIATRICDENTISTRY Vol.1, No.4 255 8. Fisher, G. C. : "Managementof Fear in the Child Patient," TABLE6. Meperidine Hcl (Demerol) and IADA, 57:792-795, 1958. PromethazineHcl (Phenergan) 9. Stewart, J. G.: "Routine Preoperative Medication in Den- tistry for Children," ] Dent Child, 28:209-212, 1961. 10. Kracke, R. R.: "Premedication in Children Undergoing Administration:* Meperidine Hcl - Oral or I.M. Single Visit Multiple Cavity Repair," ] Dent Child, 29:207- Promethazine Hcl - Oral 210, 1962. Usual Indication: Hyperkinetic or recalcitrant 11. Corbett, M. D.: "Premedication for Children," ] Dent Child, 33:125-127, 1966. Weight (Ibs) Meperidine Promethazine 12. Lampshire, E. L.: "Balanced Medication," ] Dent Child, 25-30 25 12.5 26:25-28, 1959. 30-35 37.5 12.5-18.75 13. Dudley, W.: "Premedication and the Use of Analgesics in 35-40 25-37.5 12.5-18.75 Pediatric Dentistry," Dent Clin NAmer, 865-874, October 40-45 50 25-31.25 1970. 45-55 50-62.5 25-31.25 14. Shapiro, D. N.: "Reactions of Children to Oral Surgery 55-65 50-62.5 25-37.5 Experience," ] Dent Child, 34:97-107, 1967. 85 + 50-75 25-37.5 15. Lang, L. L.: "An Evaluation of the Efficacy of Using Hydroxyzinein Controlling the Behavior of Child Patients," ] Dent Child, 32:253-258, 1959. *Parental preparations maybe combinedfor injections, but 16. Album,M. M.: "Sedatives, Analgesics, and Belladona Deri- oral routes using combinedelixir forms are generally prefer- vatives in Dentistry for Children," ] Dent Child, 26:7-13, able. For oral use: Equal parts of meperidineelixir (50mg/. 1959. 5cc) and promethazine(fortis) elixir (25 mg/5cc). One 17. Ruble, J. W.: "An Appraisal of Drugs to Premeditate spoon (5cc) will give 25 mgmeperidine and 12.5 mgprometh- azine. Twoteaspoons (10cc) will give 50 mgmeperidine and Children for Dental Procedures," ] Dent Child, 19:22-29, 25 mg of Promethazine. A reversal agent (e.g., Narcan) 1952. should be readily available in caseof emergency. 18. Kopel, H. M.: "The Use of Ataractics in Dentistry for Children," ] Dent Child, 26:14-24, 1959. 19. Lewis, H. A.: "Unconscious Castrative Significance of Tooth Extraction," ] Dent Child, 30:126-130, 1963. TABLE7. AlphaprodineHcl (Nisentil) and 20. Croxton, W. L.: "Child Behavior and the Dental Exper- PromethazineHcl (Phenergan) ience," ] Dent Child, 34:212-218, 1967. 21. Edelston, H.: "The Anxious Child," Brit Dent 1, 108:345- 349, 1960. Administration:* Alphaprodine Hcl - Submucosal 22. McDermott,J. F.: "Understanding the Nature of Children’s Promethazine Hcl - Oral Reactions to the Dental Experience," ] Dent Child, 30:126- Usual Indication: Hyperkinetic or recalcitrant 130, 1963. 23. Garfin, L. A.: Personnal Communication,1971. Weight (Ibs) Alphaprodine (mg) Promethazine (mg) 24. Hawes, R.: "The Problem of Pain and Sedation," Chapter 7 25-45 6-10 25 in Clinical Pedodontics, ed. Finn, .S.B., Philadelphia: W. 45-85 9-16 25-50 B. Saunders Co., 1973. 25. Levitas, T. C. : "Home-HandOver MouthExercise," ] Dent Child, 41:178-182, 1974. *Promethazineis given orally--30-45 minutes before sub- 26. Lampshire, E. L.: "Premedication for Children," ]ADA, mucosaladministration of alphaprodine(Nisentil). 41:407-413, 1959. A reversal agent (e.g., Narcan)should be readily available.in case of emergency. 27. Lampshire, E. L.: "Balanced Medication--An Aid for the Child Patient," Dent Clin NAmer, Nov.: 507-519, 1961. 28. Album,M. M., et al.: "Treatment of the Difficult Child," Int Dent I, 8:475-495, 1958. 29. Chambiras, P. G.: "Sedation in Dentistry: the Oral Intra- References muscular Route for the Administration of Preoperative 1. Jones, K. F.: "Preoperative Medications in Operative Sedative Drugs," Aust Dent 1, 14:84-89, 1969. Dentistry for Children," ] Dent Child, 36:93-101, 1969. 30. Harris, S. C.: "Dental Therapeutics," ]ADA, 62:502-510, 2. Wright, G. Z. and McAulay,D. J. : "Current Premedicating 1961. Trends in Pedodontics," ] Dent Child, 40:185-187, 1973. 31. Anderson, J. L.: "Use of Chloralhydrate in Dentistry," 3. Association of Pedodontic Diplomates: "Technique for Northwest Dent, 39:33-35, 1960. Behavior Management- a Survey," J Dent Child, 39:368- 32. Robbins, M. B.: "Chloralhydrate and Promethazine as 372, 1972. Premedicants for the Apprehensive Child, ] Dent Child, 4. Garfin, L. A.: "Factors in the Managementof the Child 34:327-330, 1967. Patient," ] Dent Child, 29:179-184, 1962. 33. Hoffman-LaRoche:Valium in Dentistry, 1973. 5. Olsen, N. H.: "Behavior Control of the Child Patient," 34. Main, D. M. G.: Diazepam in Anesthesia, eds. Knight, ]ADA, 68:873-877, 1964. P. F. and Burgess, C. G., Bristol: John Wright and Sons, 6. MacGregor, S. A.: "Child Management in the Dental 1968, p. 85. Office," ] CanadDent Assn, 28:75-80, 1962. 35. Sadove, M. S. and Frye, T. J.: "Preoperative Sedation 7. Chambers, D. V.: "Managing the Anxieties of Young and Production of a Quiescent State in Children," lAMA, Dental Patients," ] Dent Child, 37:363-374, 1970. 16: 1729-1733, 1957.

PREMEDICATION ATTITUDES AND AGENTS 256 King and Berlocher 36. McDonald, R. E.: Pedodontics, St.’Louis: C. V. Mosby Oxide-OxygenInhalation Sedation: an Aid in the Elimina- Co., 1963, p. 79. tion of the Child’s Fear of the Needle," Dent Clin NAmer, 37. Greenwald, A. S.: "Relief of Tension in Dental Patients: Jan.: 51-66, 1973. a Controlled Study with Dydroxyphemamate," IADA, 68: 46. Langa, H.: Relative Analgesia in Dental Practice, Philadel- 708-714, 1964. phia: W. B. Saunders Co., 1968. 38. Buckman, N.: "Balanced Premedication in Pedodontics," 47. Moiler, P,: "Treatment of the Handicapped Child," Chap- I Dent Child, 23:141-153, 1956. ter 25 in Clinical Pedodontics, ed. Fin, S. B., Philadelphia: 39. Francis, L. E. and Wood,D. R.: Dental Pharmacologyand W. B. Saunders Co., 1973. Therapeutics, Chapter 5, Philadelphia: W. B. Saunders Co., 48. Selden, H.: "Children Without Fear," N]S, Dent. Soc. 33: page 82. 240-244, 1962. 40. DeLapa, R. I.: "Influence of Alphaprodine Hydrochloride on Intravenous Barbiturate Induction Dosage," J Oral Surg, 18:163-168, 1960. DAVID L. KING is affiliated with the Department of 41. Gierson, H. W., Gottlieb, L. S., and Robin, H. J.: "Nisentil Pediatric Dentistry, The University of Texas Health as an Analgesic in Bronchoscopy," Dis Chest, 27:65-68, 1955. Science Center, San Antonio, Texas. 42. Schiffrin, M. J. and Sadove, M. S.: "Synthetic Narcotic WILLIAMC. BERLOCHERis affiliated with the Depart- Analgesics and Their Antagonists," GP, 17:106-114, 1958. ment of Pediatric Dentistry, The University of Texas 43. Robinson,D. K. : "Clinical Investigation of Three Synthetic Narcotic Drugs; a Double Blind Study," I Oral Surg, Health Science Center, San Antonio, Texas. 18:138-145, 1960. 44. Aduss, H., Bane, R. S., and Lang, L. L.: "’Pedodontic Psy- Requestsfor reprints maybe sent to Dr. David L. King, chology and Prenaedication," J Dent Child, 28:73-83, 1961. Department of Pediatric Dentistry, The University of 45. Sorenson, H. W. and Roth, G. I.: "A Case for Nitrous Texas Health Science Center, San Antonio, Texas.

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