In 2007, the American Dental Association (ADA) published Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students along with a separate set of Guidelines for the Use of Sedation and General Anesthesia by Dentists [9, 10]. The ADA guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students encourage psychological and pharmacological modalities [9]. Local anesthesia is stressed as the foundation of dental analgesia. The administration of local anesthesia, mild and moderate sedation are considered as skills that should be acquired in predoctoral or continuing education programs.

The curriculum for minimal sedation, a 16 h minimum course, should include nitrous oxide and enteral techniques. Intravenous (IV) and intramuscular techniques, in addition to the enteral and inhalation component, are taught with the moderate sedation curriculum. The Moderate Enteral Sedation Course is a minimum of 24 h didactics with ten adult cases (includes a mandatory three live adult cases). This course is not intended for the sedation of anyone under the age of 12. The Moderate Parenteral Sedation Course is a minimum of 60 h didactics and requires the management of a minimum of 20 patients via parenteral route of administration. This also is not directed for the sedation of patients <12 years of age. The sedation of <12 years of age requires additional supervised clinical experience and should follow the American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentists (AAPD) Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures [10, 11]. The administration of deep sedation and/or General Anesthesia (GA) requires separate, directed education as approved by the ADA Commission on Dental Accreditation (CODA) as well as current Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS). The accompanying clinical staff(s) of the dentist(s) who provide deep sedation and/or GA all require current BLS certification [10]. The dentist providing the deep sedation or GA is permitted to perform the dental procedures as long as there are two BLS trained individuals present—one of which is designated to monitor the patient. All deep sedation or general anesthetics require a minimum of three individuals, including the dentist providing the sedation/anesthetic [10]. All deep sedation/GA requires IV access prior to initiating the sedation with the exception of brief procedures or the poorly cooperative child. In the latter case, the IV may be initiated after deep sedation/GA is initiated [10].

Many state dental boards issue permits that are necessary before a dentist can perform sedation during dental procedures. The training requisite for permits varies according to individual state board rules and regulations and the permitting process often may involve a system that is dependent on practitioner training and route of administration of the sedative. For example, a practitioner may be issued a permit limiting his/her sedations to oral administration only. A practitioner who is issued a parenteral IV permit can use any route of administration but not progress to a depth of GA. Only an individual who has a GA permit can administer any agent via any route of administration. These sedation providers are usually dental anesthesiologists or oral and maxillofacial surgeons.

The breadth and status of teaching received by dental students about pediatric sedation is minimal [12, 13]. Furthermore, it is likely that such experiences vary widely and are probably dependent primarily on faculty training, support services, and resources at each dental institution. It is no longer possible, since the introduction of sedation permits, to sedate a patient without prior experience or training.

Specialty training in pediatric dentistry requires a minimum of 2 years and includes required didactic and clinical experiences in pharmacological management of children, according to the CODA. The extent of those experiences in clinical context, quality, and quantity has varied in the past from program to program; and standardization of experiences among the 70 plus advanced training programs was relatively unregulated and minimal. However, as a result of a report from a taskforce commissioned by the American Academy of Pediatric Dentistry (AAPD), CODA changed its accreditation standards specifically related to sedation training. Now the CODA standard for all advanced training programs in Pediatric Dentistry indicates that every resident in every program must participate in 50 sedation experiences. Furthermore, they must be the operator in 25 of the 50 cases. This new standard should impact all programs and bring more consistency and standardization to training of pediatric dentists. The overwhelming majority of programs primarily teach the use of the oral route of sedation. Rarely, IV sedation is taught and if so, a dental anesthesiologist or oral and maxillofacial surgeon provides that aspect of care.

In the private practice setting of pediatric dentistry, typically a single dentist or small group utilizes an office remote from a hospital or surgical center to provide oral health care including sedation procedures. Local resources of dental/medical anesthesiologists or other personnel trained in IV sedation are relatively rare, but growing in popularity in certain regions of the US. Otherwise, the practitioner is left with little option but to provide minimal or moderate depths of sedation via the oral route, consistent with his/her training.

Five years ago, directors of pediatric dentistry training programs indicated that as compared to a decade prior, there was an increase in the volume of sedations as well as more didactic hours devoted to sedation, and the management of sedation-related emergencies [14]. More recently, the directors of these programs have the impression that there is a greater emphasis on sedation, likely reflective of the current influence of state board regulations, professional societies, litigation, and in particular, guidelines. Similar tendencies have been addressed in the medical community [15].

In 1991, the AAPD first published a Guideline on Behavior Guidance for the Pediatric Dental Patients. These guidelines have been updated six times, as recently as 2011 [16]. These guidelines are important because they reflect the role of the entire Sedation Team, inclusive of the parents, in caring for the dental patient. The guidelines present and reinforce the role of the parents in assessing and predicting how their child will respond to the procedure, taking into account past experiences with medical procedures (see Table 20.1) [17]. Tools at patient assessment are reviewed and detailed (see Table 20.2) [16]. It also provides specific recommendations on different approaches to communicating with and interacting with a child and parents: Tell-show-do, voice control, non-verbal communication, positive reinforcement, distraction, and parental presence/absence. Techniques of Advanced Behavior Guidance are described, which include protective stabilization, sedation, and general anesthesia.

Dental anxiety and fear are thought to affect 8–20 % of children. Some have emphasized that patients with dental anxiety and fear do not necessarily display disruptive behaviors. Furthermore, some patients who do react negatively in the dental setting may not have significant fear and/or anxiety toward dental procedures [18]. Older children generally can successfully cope with the experience of sitting cooperatively for routine dental procedures (including injections) and those who cannot tend to be preschoolers and toddlers. However, there are notable subsets of older children who tend to have greater fear and anxiety over dental treatment [19]. Age, cognitive and emotional development, maturational aspects of coping with challenging situations, and other characteristics of the child are well recognized as important discriminators for the clinician in recommending certain management techniques to the parent.

Another characteristic that has shown promise in discriminating how children may react to novel clinical situations is temperament. The temperament of a child may influence the outcome of sedations and other techniques used by pediatric dentists in managing child patients [20–22]. Generally, the more approachable a child, the more likely the clinician can effectively interact and deliver care. Also, children who score differently on temperamental dimensions than their peers and have higher dental fears tend to have more negative emotionality, shyness, and higher degrees of impulsivity [19].

Several scales have been used to describe children’s behaviors during dental sedation procedures [23]. The Frankl scale is one of the more popular and widely used scales for categorizing children who may require sedation (Table 20.3) [16].

Probably the most popular scale for rating sedated children during dental procedures is the Houpt-modified scale, which relies on a categorical feature for a portion of the procedure (e.g., local anesthesia) or all portions of the entire procedure (e.g., “Fair” sedation) (see Table 20.4) [24].

Typically, a sedation appointment in a dental office or clinic involves multiple steps, all of which follow a protocol. The protocol encompasses all the steps: the informed consent process, preoperative instructions, presedation history and physical examination including airway assessment, weighing the child, administering the agent orally, waiting for a latency period wherein the effects of sedation become noticeable, placement of the child in the dental chair and the nitrous oxide (N₂O) hood over the patient’s nose, attaching monitors, proceeding with dental treatment, recovery, postoperative instructions, and discharge when appropriate criteria are attained (Fig. 20.2).

Sedative protocols used by pediatric dentists can be generally characterized as follows. The children selected for sedation are usually healthy ((American Society of Anesthesiologists) ASA I). Children who have medical conditions whose risk is more moderate to severe (greater than ASA II) are very likely to be sedated only in hospital-based settings. Most children are preschoolers although significant numbers of older children may be anxious or fearful and require sedation. Sedatives are administered almost exclusively in pediatric and general dentistry offices via the oral route consistent with the predominant type of training currently occurring in programs [14], and the behavior and physiology are recorded while the child receives routine restorative care [22, 25–37]. Usually, the behavior and physiology are documented on a time-based record by a dental assistant who performs interruptible tasks while working with the dentist. A standardized sedation recording sheet has been developed by the AAPD, Committee on Sedation and Anesthesia that conforms to the protocol portion of the AAPAAPD sedation guidelines (see Fig. 20.3).

Other incidental protocol events often include patient immobilization or stabilization (i.e., Papoose board^®) [25, 37–47]. Pediatric dentistry views the use of restraint not as punishment but as an intervention to improve the outcome or success of the sedation and procedure [48]. Pulse oximeters, blood pressure cuffs, and pretracheal or precordial stethoscopes are standard. Occasionally, side stream capnography is used but electrocardiography is rarely followed.

The choice of monitors is somewhat dependent on the behaviors exhibited by sedated children, the depth of sedation, and sedation guidelines. Behaviors and physiological parameters are fluid during the sedation, affected by the child’s reaction to the stimulation, the timing of the more intense procedural stimulation, and the dentist’s talents in calming or distracting the patient (rarely a part of study designs). For instance, heart rate typically increases most significantly and predictably during the injection of local anesthetics compared to other times of the procedure [36]. Generally, pediatric dentists target minimal or moderate sedation. Older children who require adult molar extractions, especially those that are bony impacted, the uncovering of impacted teeth, and other orthognathic surgeries are usually seen by oral and maxillofacial surgeons. Typically, they use intravenous sedation and general anesthesia in performing the aforementioned procedures.

In most practices, a parent and child arrive at least 30 min prior to the sedation procedure for preoperative assessment, consent, and further review of the medical history. The time between oral administration of sedative(s) and initiation of treatment may vary from 10 min to an hour depending on the drug or drug combination used (e.g., midazolam versus chloral hydrate [CH], respectively). The length of time involved with dental treatment ranges from 20 min to 2 h, according to the patient’s dental needs. Recovery is usually done in the dental chair or a quiet room of the dental office under direct parent and dental staff observation and monitoring. Discharge is consistent with the guidelines of the AAP and AAPD [49].

The oral route of administration remains the most popular route used by pediatric (and general) dentists in the US [7, 12–14, 50–53]. The most probable reason for this route of administration is historical and related to individual training and experience. The IV route of sedation is the most popular for oral surgeons, although their procedural need (e.g., frenectomies) to sedate preschoolers is probably much less than that of pediatric dentists. Some studies exist in which the IV route is used and managed by dental or medical anesthesiologists while the pediatric dentist performs restorative procedures in the office or outpatient care facility [54–58]. Essentially these usually involve general anesthesia administered by an individual with a GA permit or training. Various agents have been used including methohexital [58], propofol [56, 57, 59], and ketamine [59–61]. This type of care is generally limited across the US, but many pockets of the country use this protocol on a fairly frequent basis. This type of protocol seems more popular in countries outside of the US. The advantages and disadvantages of the oral route of administration compared to other routes are widely appreciated and understood even by parents.

The submucosal route is another fairly popular route of administration used by many pediatric dentists [22, 62–65]. This route of administration may limit the range and number of sedative agents that can be used (e.g., CH cannot be administered via this route), but affords a clinical onset time and sedative impact more closely resembling IV compared to the oral route in children. The clinical effects happen relatively rapidly because children usually have excellent blood supply in and around the maxillary vestibules. Caution is advised because inadvertent and rapid injection of sedatives directly into blood vessels or a venous plexus can result in a more profound effect than anticipated. The submucosal technique is relatively easy to perform, and similar to administering local anesthesia for dental procedures, hence its relative popularity among pediatric dentists.

Most of the pediatric dental studies reported in the literature focus on drugs or drug combinations involving CH, meperidine, and midazolam used in conjunction with other agents such as hydroxyzine [14, 21, 22, 24–34, 36, 37, 40, 42–44, 46, 63–114]. Occasional reports involve other benzodiazepines [41, 43, 108, 115–117] but their widespread use is not common. Rarely and usually in collaboration with a dental or medical anesthesiologist, other drugs such as ketamine are used and compared to other drugs or combinations [71, 73, 109, 118–125]. Other studies involve the IV or intramuscular routes usually done by or in collaboration with oral and maxillofacial surgeons or dental anesthesiologists for school-aged children [35, 42, 73, 89, 92, 126–135].

CH was once the most popular sedative agent in pediatric dentistry. It still remains very popular. Its dosage range when used in combination with hydroxyzine, a relatively popular regimen, is 30–50 mg/kg CH and 1–2 mg/kg of hydroxyzine. A truly effective regimen is CH, meperidine, and hydroxyzine. The dosage range in this combination varies from a “low” dose combination (15–30 mg/kg CH, 1–2 mg/kg each of meperidine and hydroxyzine) to a “high” dose combination wherein the CH is relatively high but the meperidine and hydroxyzine are low (50 mg/kg CH, 1 mg/kg meperidine, and 25 mg of hydroxyzine). There seems to be a slightly higher incidence of true desaturations and apnea episodes in the “high” compared to the “low” dose combination but further study is needed. Studies have shown this “triple combination” technique to be relatively effective and safe [26, 44, 79, 80, 84, 91]. Yet, some postoperative events may raise some concern, even if discharge criteria are met [30].

The concept behind this triple combination is that all three agents induce variable degrees of drowsiness in a dosage-dependent fashion. Meperidine also provides euphoria and analgesia, reducing the amount of local anesthetic needed. Hydroxyzine provides some protection against mucosal irritation and vomiting. The effective onset time is usually 45 min and provides procedural sedation for 60–90 min, sufficient time for significant restorative dentistry. Most patients meet discharge criteria within 30–60 min following the dental procedure [26, 44, 79, 80, 84, 91].

Midazolam in recent years has surpassed CH in popularity as the most often used sedative agent among pediatric dentists. It is most often administered orally, but the intranasal (IN) route is also used frequently [39, 75, 96, 97, 136–139]. One of the shortcomings of orally administered midazolam is its short working time that is limited to approximately 20 min of restorative care. Its advantage is that its onset of action when given by this route is 10 min or less. It is the sedative drug of choice for short restorative or extraction cases for children who require sedation. Midazolam frequently is combined with other sedatives and analgesics [31, 46, 67, 128, 140]. One of the primary purposes of combining these agents is to increase the restorative working time, take advantage of the properties of individual drugs (e.g., meperidine’s analgesic property when used with midazolam, which has no analgesic properties) and utilizing additive or potentiation effects of multiple agents, each of which may be used in lower doses. The dose of orally administered midazolam when used alone varies from 0.3 to 1.0 mg/kg. When combined with other agents, the dose usually decreases to 0.3–0.5 mg/kg. Likewise, in combination therapy the dose of meperidine is reduced from 2 to 1 mg/kg. The oral dosages of drugs, patient findings and characteristics, and concerns of these sedative agents are shown in Table 20.5. Drugs such as etomidate are not frequently utilized in the private practice community.

A recent paper reviewed the efficacy and adverse event profile of midazolam with and without narcotics, both administered via different routes [141]. All patients received local anesthesia of lidocaine with epinephrine infiltrated into the gingiva. This was an important study because it evaluated the efficacy and safety of midazolam via the oral (PO) and the intranasal (IN) route and then examined the outcome when combined with oral transmucosal fentanyl citrate (OTFC) or IN sufentanil. There were four groups: PO midazolam (1 mg/kg), IN midazolam (0.7 mg/kg), IN midazolam (0.5 mg/kg) + OTFC (10–15 μ[mu]g/kg), IN midazolam (0.3 mg/kg) + IN sufentanil (1 μg/kg). IN midazolam had shortest time to onset (17 min) and similar efficacy to all the other groups. All groups were similarly efficacious (27 % of sedations were graded as ineffective). The OTFC was the poorest performer with a 37 min time to onset and 39 min recovery (other groups 26.5–30 min). This study suggests that IN midazolam may be an efficacious method of delivery, eliminating need for parenteral administration and supplemental narcotics [141]. Still, controversy over the best route remains, as some have shown better results with the intranasal route [142] while others favor the oral [143] or intramuscular route [42].

Nitrous oxide (N₂O) is the most frequently used anxiolytic and analgesic agent used in pediatric dentistry. Typically, a nasal hood delivers nitrous oxide in an open system, thus entraining a significant amount of room air (see Fig. 20.2). In fact, adults and some children can decrease the proportion of nitrous oxide entering the lungs by breathing through their mouth (e.g., purposeful behavior or crying). The amount of N₂O entering into the lungs of patients is 30–50 % less than the amount leaving the regulator portion of the dental N₂O delivery system. Thus, if the dentist sets the N₂O flow to 50 % at the regulator, only 25–35 % of N₂O actually enters into the patient’s lung [144].

Nitrous oxide at concentrations of 30–50 % can be an excellent anxiolytic as well as a mild analgesic, via a mechanism that appears related to endogenous opioid systems [145]. For these reasons, N₂O is very frequently and effectively used with oral sedatives, primarily as the “titrating” agent for managing behavior. Another advantage to the nitrous oxide delivery system is that it provides supplemental oxygen. Nonetheless, caution must be used to consider that N₂O has been shown to inhibit the swallowing reflex [146]. There are limited studies that investigate an association between vomiting and N₂O during operative treatment in children and most suggest that vomiting is infrequent [147–149].

The true number of adverse events that occur during sedation of children for dental treatment is unknown. Most “adverse” events that are reported in the literature do not involve cardiopulmonary stabilization nor unplanned admission to a hospital [25, 28, 74, 85, 87, 88, 100]. The adverse events usually include desaturations or apnea, usually associated with patient crying and behavioral posturing, vomiting, or paradoxical excitement. More significant adverse events such as laryngospasm, seizures, or coma are less common but have been reported [150, 151].

In 2000, the incidence of significant sedation-related adverse events in pediatric patients was reviewed and published [152]. One hundred-and-eighteen case reports were reviewed. Sixty resulted in death or permanent neurological injury. Twenty-nine of these critical events occurred in children sedated for dental procedures. The occurrence of death and permanent neurological injury was more likely with the administration of three or more sedatives. Nitrous oxide in combination with other sedatives was also associated with the negative outcome [93]. It is important to realize, however, that at the time this study was published, pulse oximetry was not being used routinely and capnography was not a Standard of Care for sedation. Today, these statistics and outcomes would most likely be different.

Recent studies specifically address morbidities and mortalities associated with dental treatment of children [153, 154]. One study was based on closed claims cases involving two dental insurance companies and another involved media reports identified in the LexisNexis® Academia search engine and a private foundation formed after the death of a young child (i.e., Raven Maria Blanco Foundation). A selection bias may have weakened the strength and objectivity of the reports [154]. The studies may have some overlap with the reports previously published in 2000 [93]. These studies indicated that the majority of children who received dental treatment were less than 6 years of age and cared for by general dentists. No single sedative was consistently implicated, and some cases involved excessive/overdose amounts of local anesthetics. This data raises many issues such as whether there was appropriate clinical judgment, knowledge of or compliance with applicable clinical guidelines, and training and skills in rescue skills. Since the number of sedations actually performed annually is unknown but estimated in the hundreds of thousands, it is likely these cases represent outliers in the provision of quality sedation for oral health care.

Financial considerations of sedation for dental care are noteworthy. Most insurance plans do not cover the cost of sedation (including nitrous oxide) or anesthesia for dental procedures. Therefore, the parent is left with the financial decision of whether to pay “out of pocket” for sedation during restorative care or exodontia. However, 32 of the states have mandatory general anesthesia (GA) legislation that will cover some costs associated with the medical fees incurred during a GA for pediatric dental care (see Fig. 20.4).

The fees for sedation procedures vary considerably among dentists but may range from $100 to several hundred dollars per sedation appointment. Some states have implemented legislation requiring some third-party payors to reimburse fees associated with GA for dental restorative care. Nonetheless, often stipulations such as the patient’s age or mental or emotional status may preclude some patients from receiving care.

The alternatives to pharmacological interventions (i.e., sedation and GA) in managing fearful or uncooperative children during dental restorative or exodontia appointments may include, among others, psychological distraction techniques, hypnosis, protective stabilization (i.e., restraints such as Papoose Boards^®) or no treatment. No study has assessed the cumulative outcome of these non-pharmacological techniques and often the degree of success is subject to interpretation [48]. Anecdotally, there are many concurrent factors that have an unknown impact and interaction: the family’s cultural background, child rearing techniques, the child’s coping abilities in defending against potential physical and emotional trauma, and the quality of the work provided. Some dentists and parents perceive that if the needed treatment was completed, it was a successful outcome, regardless of the non-pharmacological techniques applied and the child’s response. This perception may be biased by the financial burden that would be incurred should pharmacological therapy be administered. Others refuse or reject these alternative means of treatment and elect not to seek care. This failure to seek treatment can have significant and event fatal consequences. Untreated dental disease does not regress and may progress to a localized abscessed condition or cellulitis. Cellulitis may be life threatening if it spreads to other organs (e.g., brain) and death may result.

Sedation guidelines for children have been followed by most pediatric dentists since they first were published in the United States in 1985 [155–157]. The first guidelines of the AAP were created as a response to deaths in dental patients who received meperidine [157–159]. The most recent joint guidelines of the AAP and AAPD emphasize, among other concepts, patient safety and rescue as well as practitioner education and training [49]. The impact of these latest guidelines (in terms of access to care, the number and types of sedations performed by pediatric dentists) remains to be seen. State dental boards regulate sedation performed by dentists. Most states require a licensed dentist also to have a special sedation permit. There are different classifications of sedation permits, such as permits for enteral versus parenteral routes of administration. Documentation of training, performance of sedation in the presence of a board consultant, and on-site inspection of offices are usually required for all permits.

Nitrous oxide inhalation sedation is the commonest method for pharmacological management of the child for dental treatment in the United Kingdom (UK). The technique and training and the suitability for usage in general dental practice was affirmed by a Directive of the European Council of Dentists in May 2012 [162].

The European Union (EU) is a culturally diverse group of countries and cultures, each with discrete laws, recommendations, and frameworks for delivery of dental services. Despite this, each member state is subject to EU law. One such law relates to specialty training: it has to be 3 years. Whilst each member state does not necessarily recognize pediatric dentistry as a specialty per se, they are surprisingly unanimous in their agreement on pediatric dental sedation and recognition of guidelines. Key in this has been the role of the International Association of Paediatric Dentistry (IAPD), and the European Academy of Paediatric Dentistry (EAPD). In a nutshell, sedation for pediatric dentistry is “conscious.” This means the child remains in verbal contact with the clinician throughout the procedure. Popularity of method and sedative varies. In Greece, oral sedatives, especially chloral hydrate have been popular; in Scandinavia rectal benzodiazepines are used; and inhalation sedation was first used in the UK in 1889 for dental cavity preparation in the Liverpool Dental School. Many countries have environmental concerns about nitrous oxide pollution; in fact, in Scandinavia amalgam filling materials are no longer used for this same reason. This is why the Directive confirming the safety and efficacy of the titrated nitrous oxide inhalation sedation technique from the Directive from the European Council of Dentists was so important. All countries have tackled the issue of the dental operator-sedationist in different ways but are generally agreed that nitrous oxide inhalation sedation, titrated to effect using dedicated dental machines, is well within a dentist’s remit and is suitable for use in high street general practice settings.

The British Commonwealth countries largely follow the UK practice and ethos relating to pediatric dental sedation; and now Middle Eastern countries are recognizing the value of titrated nitrous oxide inhalation sedation.

Children may not have sufficient maturity, capability, or reading ability to report the physiological and cognitive manifestations of anxiety. Therefore, dental anxiety scales used for them tend to concentrate on the behavioral component of anxiety and seldom follow the questionnaire format commonly used for adults. Methods of administration of the scales vary but can be broadly summarized as: (1) parental reporting of child’s anxiety, (2) child (self)-reporting, and (3) dental operator or observer reporting. To improve validity, multiple scales and methods are usually recommended to report research outcomes.

There are many different scales. A selection of those most commonly found in the literature are as follows: Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS) [198]; Modified Child Dental Anxiety Scale (MCDAS) [199]; Visual Analogue Scale (VAS) [200]; Frankl Scale [201]; Venham Picture Scale [202]; Venham Anxiety and Behavior Rating Scales [203]; Behavior Profile Rating Scale [204]; Children’s Dental Fear Picture Test [205]; Facial Image Scale (FIS) [206, 207]; and the Global Rating Scale [79]. It is this lack of standardization of scales that has led to difficulty in reporting high quality evidence in pediatric sedation studies, though the challenge actually lies in the difficulty in reporting a child’s thoughts, comprehension, and feelings in an age-specific and clinically meaningful way that is sensitive, valid and reproducible.

The Frankl scale is a common tool used for rating the behavior and patient selection in pediatric sedation studies (see Table 20.3). However, it is not sufficiently sensitive to use as a research tool; instead it is a useful as a screening tool to select participants and as an adjunct to the clinical record [79, 201, 208]. Aartman et al., 1998, reported that the CFSS-DS covered more aspects of the dental situation, measured dental fear more precisely, produced normative data, and had slightly superior psychometric properties compared to other scales. It consists of 15 items rated on a five-point scale, ranging from 1 (not afraid) to 5 (very afraid). The total score is calculated by summing item scores; giving a possible range of 15–75. Scores above 38 indicate significant dental fear. Scores from 32 to 38 indicate moderate dental anxiety and scores below 32 are considered to be low fearful [209]. Through a series of amendments to the original “Corah” scale (Table 20.7) [210], the MCDAS (Fig. 20.6) has been produced and has published UK norms [199, 211, 212]. It has eight dental anxiety items: the score in each question is from 1 (relaxed) to 5 (extremely worried), giving a total of 5–40. Scores more than 19 are considered to indicate a child is anxious and scores of more than 31 are considered to indicate a child is highly fearful. The sensitivity of the VAS has been previously confirmed for use as a measurement of state-anxiety in children and lends itself well to statistical analyses [200, 208]. Many of the other scales using pictures, such as Venham, are mainly used for very young children. However, the Venham picture scale looks very old fashioned to the eye of a modern child; the most-up-to-date and best validated scale nowadays is probably the FIS (Fig. 20.7). This is basically a five-point Likert type scale with faces rather than numbers. It is sometimes used in combination with the MCDAS [202, 205, 206].