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Estratégias farmacológicas de controlo de ansiedade em crianças na consulta dentária: uma revisão sistemática
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Introdução: Em todo o mundo, estima-se que cerca de um terço das crianças apresentem ansiedade em consultas de medicina dentária. A cooperação da criança compromete significativamente o sucesso dos tratamentos dentários, pelo que devem existir mecanismos de controlo de comportamento e ansiedade a fim de alcançar os melhores resultados possíveis. Quando os métodos tradicionais não alcançam cooperação necessária do paciente, devem-se optar por métodos farmacológicos.
Objetivo: O objetivo desta revisão sistemática é conhecer as melhores estratégias farmacológicas para o controlo de ansiedade nas crianças no consultório de medicina dentária, validadas por ensaios clínicos.
Metodologia: Foi realizada uma pesquisa através de três bases de dados, a PubMed, Web of Science e Scielo, sobre estudos clínicos randomizados, que comparassem a eficácia sedativa de diversos fármacos em crianças, com idade até aos 18 anos, que apresentassem problemas de controlo de comportamento e ansiedade. Foram avaliados diversos parâmetros entre os quais as respostas fisiológicas e sinais vitais, nível e duração da sedação, aceitação do procedimento, efeitos adversos, aceitação do fármaco e técnica, amnésia, recuperação e respostas pós-operatórias, satisfação dos pais, taxa de sucesso do tratamento e facilidade de conclusão. Realizou-se uma análise de viés dos estudos utilizando a ferramenta “Risco de viés em Ensaios clínicos randomizados - ROB 2.0”.
Resultados: Foram incluídos um total de 21 ensaios clínicos randomizados elegíveis, com um total de 2035 participantes. Dentro dos 21 estudos incluídos, apenas 5 apresentaram baixo risco de viés em todos os domínios, sendo o risco de viés geral apresenta cerca de 25% de “baixo risco”, cerca de 65% de “algumas preocupações” e cerca de 10% de “alto risco” de viés. Os estudos incluídos analisaram 15 fármacos, de forma isolada ou em combinações, sendo possível observar que os mais relevantes foram o Midazolam, a Dexmedetomidina, a Cetamina, o Óxido Nitroso e o Sevoflurano. Dentro das benzodiazepinas avaliadas, o Midazolam revelou os melhores resultados. Dentro dos anestésicos gerais, o Óxido Nitroso e o Sevoflurano foram os fármacos que se destacaram. Com base na revisão, os fármacos Midazolam, Dexmedetomidina, Cetamina, Óxido Nitroso, Sevoflurano, Tramadol, Triclofos, Clorato de Meperidina, Escetamina, Cetofol e Propofol apresentaram melhorias na diminuição da ansiedade, ao passo que os fármacos Diazepam, Hidrato de Cloral, Zolpidem e Melatonina não diminuíram a ansiedade nas crianças.
Conclusão: Os ensaios clínicos analisados mostram que associação de Midazolam com Óxido Nitroso foi a mais eficaz, bem tolerada e segura para controlo de ansiedade em crianças até aos 18 anos. Os próximos estudos deverão abranger ainda mais fármacos e combinações de forma a compreender qual a melhor estratégia farmacológica.
Introduction: Worldwide, it is estimated that about one-third of children experience anxiety during dental appointments. The child's cooperation significantly compromises the success of dental treatments, so behavior and anxiety control mechanisms must be in place to achieve the best possible results. When traditional methods fail to achieve the necessary cooperation from the patient, pharmacological methods should be used. Objective: The objective of this systematic review is to identify the best pharmacological strategies for controlling anxiety in children at the dentist's office, validated by clinical trials. Methodology: A search was conducted in three databases, PubMed, Web of Science, and Scielo, for randomized clinical studies comparing the sedative efficacy of various drugs in children up to 18 years of age who had behavior and anxiety control problems. Several parameters were evaluated, including physiological responses and vital signs, level and duration of sedation, acceptance of the procedure, adverse effects, acceptance of the drug and technique, amnesia, recovery and postoperative responses, parental satisfaction, treatment success rate, and ease of completion. A bias analysis of the studies was performed using the “Risk of Bias in Randomized Clinical Trials - ROB 2.0” tool. Results: A total of 21 eligible randomized clinical trials were included, with a total of 2035 participants. Of the 21 studies included, only 5 had a low risk of bias in all domains, with the overall risk of bias being approximately 25% “low risk,” approximately 65% “some concerns,” and approximately 10% “high risk” of bias. The included studies analyzed 15 drugs, either alone or in combination, with the most relevant being Midazolam, Dexmedetomidine, Ketamine, Nitrous Oxide, and Sevoflurane. Among the benzodiazepines evaluated, Midazolam showed the best results. Among the general anesthetics, Nitrous Oxide and Sevoflurane were the drugs that stood out. Based on the review, the drugs Midazolam, Dexmedetomidine, Ketamine, Nitrous Oxide, Sevoflurane, Tramadol, Trichlorophos, Meperidine Chlorate, Esketamine, Ketofol, and Propofol showed improvements in reducing anxiety, while Diazepam, Chloral Hydrate, Zolpidem, and Melatonin did not reduce anxiety in children. Conclusion: The clinical trials analyzed show that the combination of Midazolam and Nitrous Oxide was the most effective, well-tolerated, and safe strategy for controlling anxiety in children up to 18 years of age. Future studies should cover even more drugs and combinations in order to understand the best pharmacological strategy.
Introduction: Worldwide, it is estimated that about one-third of children experience anxiety during dental appointments. The child's cooperation significantly compromises the success of dental treatments, so behavior and anxiety control mechanisms must be in place to achieve the best possible results. When traditional methods fail to achieve the necessary cooperation from the patient, pharmacological methods should be used. Objective: The objective of this systematic review is to identify the best pharmacological strategies for controlling anxiety in children at the dentist's office, validated by clinical trials. Methodology: A search was conducted in three databases, PubMed, Web of Science, and Scielo, for randomized clinical studies comparing the sedative efficacy of various drugs in children up to 18 years of age who had behavior and anxiety control problems. Several parameters were evaluated, including physiological responses and vital signs, level and duration of sedation, acceptance of the procedure, adverse effects, acceptance of the drug and technique, amnesia, recovery and postoperative responses, parental satisfaction, treatment success rate, and ease of completion. A bias analysis of the studies was performed using the “Risk of Bias in Randomized Clinical Trials - ROB 2.0” tool. Results: A total of 21 eligible randomized clinical trials were included, with a total of 2035 participants. Of the 21 studies included, only 5 had a low risk of bias in all domains, with the overall risk of bias being approximately 25% “low risk,” approximately 65% “some concerns,” and approximately 10% “high risk” of bias. The included studies analyzed 15 drugs, either alone or in combination, with the most relevant being Midazolam, Dexmedetomidine, Ketamine, Nitrous Oxide, and Sevoflurane. Among the benzodiazepines evaluated, Midazolam showed the best results. Among the general anesthetics, Nitrous Oxide and Sevoflurane were the drugs that stood out. Based on the review, the drugs Midazolam, Dexmedetomidine, Ketamine, Nitrous Oxide, Sevoflurane, Tramadol, Trichlorophos, Meperidine Chlorate, Esketamine, Ketofol, and Propofol showed improvements in reducing anxiety, while Diazepam, Chloral Hydrate, Zolpidem, and Melatonin did not reduce anxiety in children. Conclusion: The clinical trials analyzed show that the combination of Midazolam and Nitrous Oxide was the most effective, well-tolerated, and safe strategy for controlling anxiety in children up to 18 years of age. Future studies should cover even more drugs and combinations in order to understand the best pharmacological strategy.
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Ansiedade Crianças Consulta dentária Fármacos ansiolíticos Ensaios clínicos Anxiety Children Dental consultation Anxiolytic drugs Clinical trials