Chapter 6: Topics in Pediatric Dentistry

8 CE Hours

By: Elite Staff

Learning objectives ŠŠ Identify the primary ways pediatric dentistry differs from treating ŠŠ List potential risks and contraindications for local anesthesia. adults. ŠŠ Discuss recent findings regarding xylitol and caries risk reduction. ŠŠ List the goals of behavior guidance. ŠŠ List a recommended use for restorative procedures described in ŠŠ List and describe the main components and objectives of the dental this course. consultation. ŠŠ List the clinical examination steps for unfavorable developing ŠŠ List four nonpharmacological behavior guidance strategies and dentition and occlusion. explain what is involved in each method. ŠŠ List the primary objectives for occlusion for each stage of ŠŠ Discuss some of the pros and cons of having parents present dentition. during treatment. ŠŠ Discuss the protocol for supernumerary teeth from infancy to ŠŠ Explain why nitrous oxide is typically preferred over protective young adolescent. stabilization as an advanced behavior guidance strategy. ŠŠ Describe the characteristics, causes and management of ŠŠ List contraindications and potential adverse effects for nitrous odontogenic infections in children. oxide/oxygen inhalation. ŠŠ Discuss the risks associated with excessive antibiotic therapy. ŠŠ List documentation requirements for deep sedation/general anesthesia.

Introduction Pediatric dentistry differs from treating adults in a number of ●● Nitrous oxide use. significant ways. While the dental professional’s primary objective is ●● Local anesthesia use. always to facilitate optimum oral health for the patient through the best ●● Caries risk-assessment and management. prevention and treatment methods, practitioners working with children ●● Restorative dentistry. also have the priority of creating a positive formative experience, ●● Management of the developing dentition and occlusion. placing additional emphasis on establishing a safe, comfortable ●● Oral surgery. atmosphere, communicating the importance of proper dental care, and Throughout the chapter, list items are characterized by the following paving the way for lifelong positive dental experiences. bullet points to note their significance: Recent years have brought changes in best practices for working with ŠŠ Objectives. pediatric patients. This chapter provides updated guidelines for the ++ Indications/recommendations. following practices and procedures specifically related to the child XX Contraindications. patient: * Risks/cautions. ●● Basic behavior guidance strategies. 99 Documentation requirements. ●● Advanced behavior guidance.

Basic behavior guidance strategies for the child patient This section introduces behavior guidance concepts that dental The proper implementation of behavior guidance strategies requires professionals can use to address fear, anxiety or inappropriate an understanding of the scientific principles on which they are based. behavior in young patients during dental procedures. Revised in 2011 But it is more than pure science. Effective behavior guidance requires by the American Association of Pediatric Dentists, it reviews basic not only the appropriate theoretical knowledge, but also the ability communication strategies, including proper implementation of the to implement communication and active listening skills as well as following interventions and practices: empathy, tolerance and flexibility. This section will touch briefly ●● Obtaining informed consent. on these strategies, but much more detailed information is readily ●● Patient communication. available. Effective behavior guidance is a clinical art form and a skill, ●● Tell-Show-Do technique. requiring a solid grounding in both theoretical and practical issues. ●● Voice control. These methods are critical not only because they affect the child and ●● Nonverbal communication. his parent’s attitude toward dentistry, potentially affecting dental care ●● Positive reinforcement. for the rest of his life, but also because they affect your business. ●● Distraction. Obviously, how a dentist interacts with patients greatly influences his ●● Parental presence/absence. or her professional success. Studies suggest that dentists’ technical ●● Nitrous oxide/oxygen inhalation. skills are often judged by their “bedside manner,” or how caring and ●● Protective stabilization. sympathetic they are perceived to be, which is largely a function of ●● Sedation. communication skills. ●● General anesthesia.

Dental.EliteCME.com Page 113 The goals of behavior guidance are to: share in the decision-making process on treatment of their ŠŠ Establish communication. children. ŠŠ Alleviate fear and anxiety. ●● The staff must be trained carefully to support the dentist’s ŠŠ Deliver quality dental care. efforts and welcome the patient and parent into a child-friendly ŠŠ Build a trusting relationship between dentist, child and parent. environment that will facilitate behavior guidance and a positive ŠŠ Promote the child’s positive attitude toward oral/dental health and dental visit. oral health care. ●● Pain management during dental procedures is crucial for To achieve these objectives, dental professionals should implement successful behavior guidance and enhancing positive dental measures that take the following factors into account: attitudes for future visits. Listening to the child and observing ●● The urgency of the child’s dental needs must be considered his or her behavior at the first sign of distress will be helpful in when planning treatment. Deferral or modification of treatment diagnosing the situation and facilitating proper behavior guidance sometimes may be necessary until routine care can be provided techniques. using appropriate behavior guidance techniques. ●● Parents exert a significant influence on the behavior of their ●● All decisions on use of behavior guidance techniques must be children. Educating the parents before their child’s visit may be based upon a benefit vs. risk evaluation. As part of the process of helpful and promote a positive dental experience. obtaining informed consent, the dentist’s recommendations on ●● Dentists should record the patient’s behavior at each visit. This use of techniques (other than communicative guidance) must be will serve as a documentation of past behavior and aid in diagnosis explained to the parents’ understanding and acceptance. Parents for future visits.

Stages of child development Many different theories and categorization of child development exist. 3. Concrete operations: From about 7 to 11 years of age; child Perhaps the most well-known is Piaget’s stage theory, describing the is able to apply logical reasoning, consider another person’s cognitive development of children. Although stages of psychological point of view, and assess more than one aspect of a particular and physical development vary greatly by child, certain qualitative situation. Characterized by concrete thinking. age-associated differences in development can be noted in most 4. Formal operations: Begins at about 11 years of age; logical children. The dental team should be aware of these important abstract thinking develops, allowing the child to consider psychological milestones: different possibilities for action. ●● Motor development ●● Perceptual development Range of movement develops rapidly. By 2 years of age, most Between the ages of 6 and 7 years, a child begins to determine children are capable of walking on their own. Children 6 to 7 years what information merits greater attention and what can be old usually have sufficient coordination to brush their teeth, though ignored. Concentration improves. At this age, dentists can begin it varies greatly by child. Parental supervision of brushing is very to impart dental advice directly to the patient. Because the home important, but critical for younger children, who are likely to miss environment will still be the main source of information, it is areas of the mouth and may swallow large amounts of toothpaste. crucial to explain proper dental care to the patient’s parents so they ●● Cognitive development can guide the effort. Piaget discussed four main stages of cognitive development: ●● Social development 1. Sensorimotor: About 2 years of age; child develops an Fear of strangers is pronounced in many infants at about 8 months understanding that items exist even when not experienced of age, with anxiety separation relatively common for children directly (called “object permanence”). until about 5 years of age, when it declines markedly. 2. Preoperational thought: From about 2 to 7 years of age; child becomes able to predict outcomes (causation). Language develops.

Anxiety A closer study of anxiety is necessary to addressing it in both children age-appropriate explanation before any procedure can reduce patient and adult patients. Kent and Blinkhorn [1991] describe anxiety as anxiety. a “vague unpleasant feeling accompanied by a premonition that The best way to reduce potential for anxiety is to establish an something undesirable is going to happen.” An added dimension effective preventive care program that includes sufficient time during not noted in this definition is that anxiety often manifests itself in or each session for the patient and dental team to develop a trusting motivates behavior, such as avoiding dental appointments. It also is relationship in which the dentist: an additional stress to the dental practitioner, who does not want to ●● Listens to the child. contribute to the anxiety in any way. ●● Addresses any concerns or worries. Children are much more vulnerable and fearful than most adults. They ●● Ensures that treatment is pain-free. are less comfortable in new surroundings and not amenable to rushing. Anxiety and fear are closely related. In many cases, the two terms can Therefore, effective time management is critical. Do not overschedule, be used interchangeably. While anxiety more often stresses feelings of and do your best to see young patients on time. Never attempt to discomfort, fear describes a stronger reaction to a specific event, one complete a clinical task in a short time on an apprehensive patient. that may trigger the flight/fight response. A phobia is intense fear that Poor past experiences and learned anxiety responses from family is egregiously out of proportion to the actual threat. Despite a dental members and friends are common sources of anxiety in children. team’s best efforts, anxiety may persist or escalate, with dental care Additionally, anxiety is often related to uncertainty about what is compromised unless interventions such as pharmacological agents are about to happen. In each of these cases, a relaxed and thorough used.

Page 114 Dental.EliteCME.com Communication strategies/management Communicative management and appropriate use of commands are Rather than being a collection of singular techniques, communicative used universally in pediatric dentistry with both the cooperative management is an ongoing subjective process that becomes an and uncooperative child. In addition to establishing a relationship extension of the personality of the dentist. Associated with this process with the child and allowing for the successful completion of dental are the specific techniques of tell-show-do, voice control, nonverbal procedures, these techniques may help the child develop a positive communication, positive reinforcement and distraction. The dentist attitude toward oral health. Communicative management comprises should consider the cognitive development of the patient as well as a host of techniques that, when integrated, enhance the evolution of a the presence of other communication deficits (e.g., hearing disorder), cooperative patient. when choosing specific communicative management techniques.

The dental consultation This section outlines basic steps for a dental consultation with a child continue to ask them specifically about pain or discomfort as you patient: are working. An excellent strategy that is educational, calming, 1. Greeting: The dentist should greet the child by name. Parents and easy for you is to discuss specifically what you are doing as should be included in the conversation, but the child should be are doing it. your central focus. The greeting should put the child and parents at ○○ At the end of the dental procedure it is helpful to summarize ease. At this point, the child can be invited to sit in the dental chair, what has been done and discuss aftercare. The parents must or the first part of the preliminary talk can occur with the child in a understand the treatment summary because they need to regular seat. understand what was done and to oversee the aftercare. 2. Preliminary discussion: This portion has three main goals: 5. Health education: Because oral health is so dependent on ○○ To assess worries or concerns on behalf of the patient or personal behavior, it is essential that patients learn how to maintain parents. a healthy mouth. Here are some key ways to improve the value of ○○ To make the patient feel comfortable in the clinical advice given to patients and their parents: environment. ○○ Make the advice specific, simple and precise. ○○ To assess the patient’s emotional state. ○○ Provide written information with diagrams for the patient to ■■ Many dentists find it is best to begin by discussing non- take home. dental topics. Record notes for future reference, and ○○ Do not suggest goals that require unrealistic behavioral review notes from siblings or family members to acquaint changes. Instead, encourage patients to change habits or reacquaint yourself with the patient. Information should gradually; i.e., if brushing only once a day, suggest they brush include names of brothers/sisters, school, pets and hobbies. morning and night instead of after every meal. ■■ Ask open-ended question such as “Are you having any ○○ Confirm the information has been understood and not problems or pain with your teeth?” Never phrase the misinterpreted by having the patient repeat it back to you. question to imply a certain answer (such as “You’re not ○○ Offer advice in such a way that the child and parents do not having any problems or pain with your teeth, are you?”). feel threatened or blamed. Really listen to the answer, including any hesitation ○○ To improve oral hygiene, use practical demonstrations rather or uncertainty. Sometimes children have difficulty than theoretical discussions. characterizing or describing what they are experiencing ○○ Reinforce the advice and offer positive reinforcement at because their language skills are not fully developed. Once follow-up visits. you have listened and clarified the answer, probe further ○○ The final portion of this step is goal setting, in which the for more detail, if necessary. You will find that simply dentist briefly discusses the patient’s responsibilities at talking to the patient and taking note of what he or she home and what he or she should try to achieve by the next is saying increases the person’s feelings of control and visit. This discussion clarifies to both children and parents reduces anxiety. what is expected of them to maintain or improve the child’s 3. Preliminary explanation. This section requires the dentist to oral health. Sensitivity for parents’ feelings is important, communicate the clinical or preventive objectives in terms that because they may feel the dentist does not understand their parents and children will understand. It is critical that the dentist is problems or that they are being blamed for their child’s dental able to state the goals of treatment in non-technical language. shortcomings. It is important that goal setting is done in a 4. Dental procedure: This is where the clinical work begins. While cooperative and friendly manner. you cannot carry on a conversation with the patient, you cannot 6. Departure: This appointment is over. The next appointment treat him or her as a passive object, either. The patient should should be scheduled and office business completed. The patient be encouraged to respond with verbal signs. Tell them to let you should be addressed by name and bid goodbye, leaving pain-free know in a specific way if they are in discomfort or pain, but also with a sense of goodwill.

Nonpharmacological strategies to reduce uncertainty and anxiety Most young children have no real sense of what dental treatment 2. Show: Demonstrations for the patient of the visual, auditory, involves before they experience it, and this will raise anxiety levels. olfactory and tactile aspects of the procedure in a carefully defined, Friendly reassurance is enough for some patients, but others will need nonthreatening setting. more structured methods. 3. Do: Without deviating from the explanation and demonstration, Tell-show-do is a technique of verbal and nonverbal communication completion of the procedure. behavior shaping used by many pediatric professionals. The technique The tell-show-do technique is used with communication skills (verbal involves: and nonverbal) and positive reinforcement. The patient should be 1. Tell: Verbal explanations of procedures in phrases appropriate to praised throughout the procedure. the developmental level of the patient.

Dental.EliteCME.com Page 115 The objectives of tell-show-do are to: children on a sporadic basis. Distraction, however, is one cognitive ŠŠ Teach the patient important aspects of the dental visit. approach that is very effective with children. This technique attempts ŠŠ Familiarize the patient with the dental setting. to divert attention from the dental procedure to something more ŠŠ Shape the patient’s response to procedures through desensitization pleasant, such as cartoons or video games. Giving the patient a short and well-described expectations. break during a stressful procedure can also be an effective use of Voice control is a controlled alteration of voice volume, tone or pace distraction before considering more advanced behavior guidance to influence and direct the patient’s behavior. Parents unfamiliar with techniques. this possibly aversive technique may benefit from an explanation The objectives of distraction are to: before its use to prevent misunderstanding. ŠŠ Decrease the perception of unpleasantness. Š The objectives of voice control are to: Š Avert negative or avoidance behavior. ŠŠ Gain the patient’s attention and compliance. Modeling – Children learn a great deal about the world by seeing other ŠŠ Avert negative or avoidance behavior. people’s behaviors and its consequences. Children are more inclined to ŠŠ Establish appropriate adult-child roles. behave in ways they see rewarded rather than punished. Modeling is Nonverbal communication is the reinforcement and guidance of a useful way to “show” that a procedure is not to be feared. To do this behavior through appropriate contact, posture, facial expression and requires seeing another child have a good experience with the same body language. procedure. While it’s not necessary to produce a live model (videos of cooperative patients can be useful), older siblings, other family The objectives of nonverbal communication are to: members and even friends can be very helpful in this regard. ŠŠ Enhance the effectiveness of other communicative management techniques. The most effective modeling programs, however, show videos or use ŠŠ Gain or maintain the patient’s attention and compliance. children close in age to the child involved. The model should be shown entering and leaving treatment with no negative effects (although Positive reinforcement is the process of establishing desirable discussion of tenderness or other common symptoms after dental work patient behavior, it is essential to give appropriate feedback. Positive should be discussed). The dentist should praise the patient throughout. reinforcement is an effective technique to reward desired behaviors and thus strengthen the recurrence of those behaviors. Social A note about hand over mouth exercise (HOME): Hand over reinforcers include positive voice modulation, facial expression, verbal mouth exercise has been eliminated from the clinical guidelines of the praise and appropriate physical demonstrations of affection by all American Association of Pediatric Dentistry. This conditioning method members of the dental team. Nonsocial reinforcers include tokens and was originally recommended in 1929 as a last resort for use by dentists toys. to control a child (typically over 3 years old) who would not cooperate while undergoing a dental procedure. It should no longer be used. Distraction – while cognitive approaches are useful in reducing anxiety in adults, it is difficult to implement most of them with

Parental influence on dental treatment Children learn the most basic aspects of life from their parents in a parent’s presence may also divide the child’s attention, taking it away process known as socialization. Fear of dental treatment and patterns from the dentist. Parents in the treatment room noted the following of dental hygiene are typically learned in the family. Because parents potentially obstructive behaviors: are the primary influence in children’s attitudes about oral health care, ●● Repeating orders, creating excess noise and annoyance for the they must be involved in any attempts to shape a child’s dental care dental team or child. habits. Discussion with parents must always use positive reinforcement ●● Becoming an obstacle to the to the development of rapport and avoid anything that may be interpreted as “blaming.” Parents may between the dentist and the child. feel sensitive, threatened or guilty about a child’s compromised dental ●● Interfering with behavioral guidance or communication strategies. health. These emotions result in excuses, and if intense enough, an end ●● Being defensive or taking offense at something said. to the child’s dental visits. ●● Contributing to physical crowding of the dental team. Parental presence/absence – The objectives of parental presence/ A wide diversity exists in practitioner philosophy and parental attitudes absence are for parents to participate in infant examinations about parents’ presence or absence during pediatric dental treatment. and treatment if asked; offer very young children physical and Parental involvement, especially in their children’s health care, has psychological support; and observe the reality of their child’s changed dramatically in recent years. Increasingly, parents expect to treatment. This allows practitioners to achieve the following goals, be with their infants and young children during examinations as well which are necessary to providing therapeutic services: as during treatment. Parents’ desire to be present during their child’s ŠŠ Gain the patient’s attention and improve compliance. treatment should not be interpreted to mean they distrust the dentist ŠŠ Avert negative or avoidance behaviors. in any way. More often, it suggests they are uncomfortable if they ŠŠ Establish appropriate dentist-child roles. visually cannot verify their child’s safety. ŠŠ Enhance effective communication among the dentist, child and It is important to understand the changing emotional needs of parents parent. because of the growth of a latent but natural sense to be protective of ŠŠ Minimize anxiety and achieve a positive dental experience. their children. Practitioners should become accustomed to this added ŠŠ Facilitate rapid informed consent for changes in treatment or involvement of parents and welcome the questions and concerns for behavior guidance. their children. Practitioners must consider parents’ desires and wishes Unfortunately, in some cases, parents are unwilling or unable to extend and be open to a paradigm shift in their own thinking. effective support when asked. Parents may themselves be anxious about dental care and communicate that fear to their children. A

Page 116 Dental.EliteCME.com Advanced behavior guidance Most children can be managed effectively using basic behavior ++ Patients who cannot cooperate because of a lack of psychological guidance strategies. Some children, however, present behavioral or emotional maturity or mental, physical or medical disability. considerations that require more advanced techniques. These children ++ Patients for whom the use of sedation may protect the developing often cannot cooperate because of a lack psychological or emotional psyche or reduce medical risk. maturity or mental, physical or medical disabilities. The use of sedation is contraindicated for: The advanced behavior guidance techniques commonly used and XX The cooperative patient with minimal dental needs. taught in advanced pediatric dental training programs include XX Predisposing medical conditions or physical conditions that would protective stabilization, sedation and general anesthesia. They are make sedation inadvisable. extensions of the overall behavior guidance continuum with the intent General anesthesia is a controlled state of unconsciousness to facilitate the goals of communication, cooperation and delivery of accompanied by a loss of protective reflexes, including the ability quality oral health care in the difficult patient. Skillful diagnosis of to maintain an airway independently and respond purposefully to behavior and safe and effective implementation of these techniques physical stimulation or verbal command. The use of general anesthesia necessitate knowledge and experience that are generally beyond the sometimes is necessary to provide quality dental care for the child. core knowledge students receive during predoctoral dental education. Depending on the patient, this can be done in a hospital or an While most predoctoral programs provide didactic exposure to ambulatory setting, including the dental office. treatment of very young children (i.e., aged birth-2 years), patients The need to diagnose and treat as well as the safety of the patient, with special health care needs, advanced behavior guidance techniques practitioner and staff should be considered for the use of general and hands-on experience are lacking. A minority of programs provides anesthesia. The decision to use general anesthesia must take into educational experiences with these patient populations, but few consideration: provide hands-on exposure to advanced behavior guidance techniques. ●● Alternative behavioral guidance modalities. On average, predoctoral pediatric dentistry programs teach students ●● Dental needs of the patient. to treat children 4 years of age and older who are generally well- ●● The effect on the quality of dental care. behaved and have low levels of caries. Dentists considering the use of ●● The patient’s emotional development. these advanced behavior guidance techniques should seek additional ●● The patient’s medical status. training through a residency program, a graduate program, or an extensive continuing education course that involves both didactic and The goals of general anesthesia are to: experiential mentored training. ŠŠ Provide safe, efficient and effective dental care. ŠŠ Eliminate anxiety. Sedation can be used safely and effectively with patients unable to ŠŠ Reduce untoward movement and reaction to dental treatment. receive dental care for reasons of age or mental, physical or medical ŠŠ Aid in treatment of the young, mentally, physically or medically condition. The need to diagnose and treat as well as the safety of compromised patient. the patient, practitioner and staff should be considered for the use ŠŠ Eliminate the patient’s pain response. of sedation. The decision to use any type of sedation must take into consideration: Prior to the delivery of general anesthesia, appropriate documentation ●● Alternative behavioral guidance modalities. shall address the rationale for use of general anesthesia, informed ●● Dental needs of the patient. consent, instructions provided to the parent, dietary precautions and ●● The effect on the quality of dental care. preoperative health evaluation. Because laws and codes vary from ●● The patient’s emotional development. state to state, minimal requirements for a time-based anesthesia record ●● The patient’s medical and physical considerations. should include: 99 The patient’s heart rate, blood pressure, respiratory rate and The goals of sedation are to: oxygen saturation at specific intervals throughout the procedure ŠŠ Guard the patient’s safety and welfare. and until predetermined discharge criteria have been attained. ŠŠ Minimize physical discomfort and pain. 99 The name, route, site, time, dosage and patient effect of ŠŠ Control anxiety, minimize psychological trauma, and maximize the administered drugs, including local anesthesia. potential for amnesia. 99 Adverse events (if any) and their treatment. ŠŠ Control behavior and movement to allow the safe completion of 99 That discharge criteria have been met, the time and condition the procedure. of the patient at discharge, and into whose care the discharge ŠŠ Return the patient to a state in which safe discharge from medical occurred. supervision, as determined by recognized criteria, is possible. General anesthesia is indicated for: Documentation must include: ++ Patients who cannot cooperate due to a lack of psychological or 99 Informed consent must be obtained from the parent and emotional maturity or mental, physical or medical disability. documented prior to the use of sedation. ++ Patients for whom local anesthesia is ineffective because of acute 99 Instructions and information provided to the parent. infection, anatomic variations or allergy. 99 Health evaluation. ++ The extremely uncooperative, fearful, anxious or 99 A time-based record that includes the name, route, site, time, uncommunicative child or adolescent. dosage and patient effect of administered drugs. ++ Patients requiring significant surgical procedures. 99 The patient’s level of consciousness, responsiveness, heart rate, ++ Patients for whom the use of general anesthesia may protect the blood pressure, respiratory rate and oxygen saturation at the time developing psyche or reduce medical risk. of treatment and until predetermined discharge criteria have been ++ Patients requiring immediate, comprehensive oral/dental care. attained. 99 Adverse events (if any) and their treatment. The use of general anesthesia is contraindicated for: 99 Time and condition of the patient at discharge. XX A healthy, cooperative patient with minimal dental needs. XX Predisposing medical conditions that would make general Sedation is indicated for: anesthesia inadvisable. ++ Fearful, anxious patients for whom basic behavior guidance techniques have not been successful.

Dental.EliteCME.com Page 117 Protective stabilization – The broad definition of protective ŠŠ Facilitate delivery of quality dental treatment. stabilization is the restriction of patient’s freedom of movement, with The patient’s record must include: or without the patient’s permission, to decrease risk of injury while 99 Informed consent for stabilization. allowing safe completion of treatment. The restriction may involve 99 Indication for stabilization. another human, a patient stabilization device, or a combination thereof. 99 Type of stabilization. The use of any type of protective stabilization in the treatment of 99 The duration of application of stabilization. infants, children, adolescents or patients with special health care 99 Behavior evaluation/rating during stabilization. needs is a topic that concerns health care providers, caregivers and Patient stabilization is indicated when: the public. It is rare that a better strategy cannot be found, because ++ Patients require immediate diagnosis or limited treatment and the use of protective stabilization has the potential to produce serious cannot cooperate because of a lack of maturity or mental or consequences, such as physical or psychological harm, loss of dignity physical disability. and violation of a patient’s rights. Stabilization devices placed around ++ The safety of the patient, staff, dentist or parent would be at risk the chest may restrict respirations; they must be used with caution, without the use of protective stabilization. especially for patients with respiratory compromise (e.g., asthma) or ++ Sedated patients require limited stabilization to help reduce who will receive medications (i.e., local anesthetics, sedatives) that untoward movement. can depress respirations. Because of the associated risks and possible consequences of use, the dentist is encouraged to evaluate thoroughly Patient stabilization is contraindicated for: its use on each patient and possible alternatives. Careful, continuous XX Cooperative, non-sedated patients. monitoring of the patient is mandatory during protective stabilization. XX Patients who cannot be immobilized safely because of associated medical or physical conditions. In very rare cases, partial or complete stabilization of the patient may XX Patients who have experienced previous physical or psychological be necessary to protect the patient, practitioner, staff or the parent trauma from protective stabilization (unless no other alternatives from injury while providing dental care. Protective stabilization can are available). be performed by the dentist, staff or parent with or without the aid of XX Non-sedated patients with non-emergent treatment requiring a restrictive device. The dentist always should use the least restrictive lengthy appointments. but safe and effective protective stabilization. The use of a mouth prop in a compliant child is not considered protective stabilization. The following precautions should be taken: * The patient’s medical history must be reviewed carefully to The need to diagnose, treat and protect the safety of the patient, ascertain whether there are any medical conditions (e.g., asthma) practitioner, staff and parent should be considered before the use of that may compromise respiratory function. protective stabilization. The decision to use protective stabilization * Tightness and duration of the stabilization must be monitored and must take into consideration: reassessed at regular intervals. ●● Alternate behavior guidance modalities. * Stabilization around extremities or the chest must not actively ●● Dental needs of the patient. restrict circulation or respiration. ●● The effect on the quality of dental care. * Stabilization should be terminated as soon as possible in a patient ●● The patient’s emotional development. who is experiencing severe stress or hysterics to prevent possible ●● The patient’s emotional and physical considerations. physical or psychological trauma. Protective stabilization, with or without a restrictive device, performed Potential benefits: by the dental team, requires informed consent from a parent. Informed ++ Reduction in pain and anxiety of pediatric dental patients with consent must be obtained and documented in the patient’s record prior special health care needs. to use of protective stabilization. Because of the possible aversive ++ Increase in safety and quality of care for pediatric dental patients. nature of the technique, informed consent also should be obtained ++ Increase in safety of dental staff. before a parent performs protective stabilization during dental procedures. Furthermore, when appropriate, an explanation to the Potential risks: patient about the need for restraint, with an opportunity for the patient * The use of protective stabilization has the potential to produce to respond, should occur. serious consequences, such as physical or psychological harm, loss of dignity and violation of a patient’s rights. Stabilization In the event of an unanticipated reaction to dental treatment, it is devices placed around the chest may restrict respirations; they incumbent upon the practitioner to protect the patient and staff from must be used with caution, especially for patients with respiratory harm. Following immediate intervention to assure safety, if techniques compromise (e.g., asthma) or who will receive medications (i.e., must be altered to continue delivery of care, the dentist must have local anesthetics, sedatives) that can depress respirations. Because informed consent for the alternative methods. of the associated risks and possible consequences of use, the The objectives of patient stabilization are to: dentist is encouraged to evaluate thoroughly its use on each patient ŠŠ Reduce or eliminate untoward movement. and possible alternatives. Careful, continuous monitoring of the ŠŠ Protect patient, staff, dentist, or parent from injury. patient is mandatory during protective stabilization.

Nitrous oxide use and the child patient Nitrous oxide/oxygen inhalation is a safe and effective technique indications, contraindications and additional clinical considerations, to reduce anxiety and enhance effective communication. Its onset revised in 2009 by the American Association of Pediatric Dentists, are of action is rapid, the effects easily are titrated and reversible, and provided here. recovery is rapid and complete. Additionally, nitrous oxide/oxygen This section provides information to help you develop appropriate inhalation mediates a variable degree of analgesia, amnesia and gag practices in the use of nitrous oxide/oxygen analgesia/anxiolysis reflex reduction. for pediatric patients. Indications for use of nitrous oxide/oxygen However, the need to diagnose and treat as well as the safety of the analgesia/anxiolysis include: patient and practitioner should be considered before the use of nitrous ++ A fearful, anxious, or obstreperous patient. oxide/oxygen analgesia/anxiolysis. Detailed information about the ++ Certain patients with special health care needs.

Page 118 Dental.EliteCME.com ++ A patient whose gag reflex interferes with dental care. pulmonary disease, congestive heart failure, sickle cell disease, acute ++ A patient for whom profound local anesthesia cannot be obtained. otitis media, recent tympanic membrane graft, acute severe head ++ A cooperative child undergoing a lengthy dental procedure. injury). Review of the patient’s medical history should be performed before This section examines the following points: making a decision to use nitrous oxide/oxygen analgesia/anxiolysis. Management This assessment should include: ●● Technique of nitrous oxide/oxygen administration. 99 Allergies and previous allergic or adverse drug reactions. ●● Patient monitoring during procedure (patient’s responsiveness, 99 Current medications including dose, time, route, and site of color, respiratory rate and rhythm, spoken responses). administration. ●● Documentation. 99 Diseases, disorders or physical abnormalities and pregnancy status. ○○ Informed consent. 99 Previous hospitalization to include the date and purpose. ○○ Provision of instructions to the parent (regarding pre-treatment Contraindications for use of nitrous oxide/oxygen inhalation may dietary precautions). include: ○○ Recording of indication, dose, flow, procedure duration, post- XX Some chronic obstructive pulmonary diseases. treatment oxygenation procedure. XX Severe emotional disturbances or drug-related dependencies. Facilities/personnel/equipment XX First trimester of pregnancy. ●● Proper gas delivery and fail-safe function. XX Treatment with bleomycin sulfate. ●● Appropriate oxygen concentration. XX Methylenetetrahydrofolate reductase deficiency. ●● Training and certification in basic life support for all clinical Whenever possible, appropriate medical specialists should be personnel. consulted before administering analgesic/anxiolytic agents to patients ●● Periodic review of safety procedures (the office’s emergency with significant underlying medical conditions (e.g., severe obstructive protocol, the emergency drug cart, and simulated exercises to assure proper emergency management response).

Administration technique Nitrous oxide/oxygen must be administered only by appropriately ++ Enhanced communication and patient cooperation. licensed individuals or under the direct supervision thereof, according ++ Raised pain reaction threshold. to state law. The practitioner responsible for the treatment of the ++ Increased tolerance for longer appointments. patient and the administration of analgesic/anxiolytic agents must ++ Aided treatment of the mentally/physically disabled or medically be trained in the use of such agents and techniques and appropriate compromised patient. emergency response. ++ Reduced gagging. Selection of an appropriately sized nasal hood should be made. A flow ++ Potentiated effect of other sedatives. rate of 5 to 6 liters/minute generally is acceptable to most patients. The Potential risks: flow rate can be adjusted after observation of the reservoir bag.The * Some patients fear “losing control” with the use of nitrous oxide. bag should pulsate gently with each breath and should not be either * Claustrophobic patients may find the nasal hood confining and over- or underinflated. Introduction of 100 percent oxygen for 1-2 unpleasant. minutes followed by titration of nitrous oxide in 10 percent intervals * Side effects including nausea, vomiting, headache and is recommended. During nitrous oxide/oxygen analgesia/anxiolysis, disorientation. the concentration of nitrous oxide should not routinely exceed 50 * Although rare, silent regurgitation and subsequent aspiration need percent. Nitrous oxide concentration may be decreased during easier to be considered with nitrous oxide/oxygen sedation. The concern procedures (e.g., restorations) and increased during more stimulating lies in whether pharyngeal-laryngeal reflexes remain intact. ones (e.g., extraction, injection of local anesthetic). * Interference of the nasal hood with injection to anterior maxillary During treatment, it is important to continue the visual monitoring of region. the patient’s respiratory rate and level of consciousness. The effects * Nitrous oxide pollution and potential occupational exposure health of nitrous oxide largely are dependent on psychological reassurance. hazards. Therefore, it is important to continue traditional behavior guidance Contraindications for use of nitrous oxide/oxygen inhalation may techniques during treatment. Once the nitrous oxide flow is terminated, include: 100 percent oxygen should be delivered for three to five minutes.The XX Some chronic obstructive pulmonary diseases. patient must return to pre-treatment responsiveness before discharge. XX Severe emotional disturbances or drug-related dependencies. Potential benefits: XX First trimester of pregnancy. ++ Reduction or elimination of anxiety. XX Treatment with bleomycin sulfate. ++ Reduced movement and reaction to dental treatment. XX Methylenetetrahydrofolate reductase deficiency.

Monitoring The response of patients to commands during procedures responsiveness, color and respiratory rate and rhythm must be performed with anxiolysis/analgesia serves as a guide to their performed. Spoken responses provide an indication that the patient level of consciousness. Clinical observation of the patient must be is breathing. If any other pharmacologic agent is used in addition to done during any dental procedure. During nitrous oxide/oxygen nitrous oxide/oxygen and a local anesthetic, monitoring guidelines for analgesia/anxiolysis, continual clinical observation of the patient’s the appropriate level of sedation must be followed.

Adverse effects of nitrous oxide/oxygen inhalation Nitrous oxide/oxygen analgesia/anxiolysis has an excellent safety a safe and effective agent for providing pharmacological guidance record. When administered by trained personnel on carefully selected of behavior in children. Acute and chronic adverse effects of nitrous patients with appropriate equipment and technique, nitrous oxide is oxide on the patient are rare. Nausea and vomiting are the most

Dental.EliteCME.com Page 119 common adverse effects, occurring in 0.5 percent of patients. A higher Documentation incidence is noted with longer administration of nitrous oxide/oxygen, Informed consent must be obtained from the parent and documented fluctuations in nitrous oxide levels, and increased concentrations of in the patient’s record prior to administration of nitrous oxide/oxygen. nitrous oxide. The practitioner should provide instructions to the parent regarding pre-treatment dietary precautions, if indicated. In addition, the patient’s Fasting is not required for patients undergoing nitrous oxide analgesia/ record should include: anxiolysis. The practitioner, however, may recommend that only a 99 Indication for use of nitrous oxide/oxygen inhalation. light meal be consumed in the two hours prior to the administration 99 Nitrous oxide dosage (i.e., percent nitrous oxide/oxygen and/or of nitrous oxide. Diffusion hypoxia can occur as a result of rapid flow rate). release of nitrous oxide from the blood stream into the alveoli, thereby 99 Duration of the procedure. diluting the concentration of oxygen. This may lead to headache 99 Post-treatment oxygenation procedure. and disorientation and can be avoided by administering 100 percent oxygen after nitrous oxide has been discontinued.

Facilities/personnel/equipment All newly installed facilities for delivering nitrous oxide/oxygen These individuals should participate in periodic review of the office’s must be checked for proper gas delivery and fail-safe function before emergency protocol, the emergency drug cart, and simulated exercises use. Inhalation equipment must have the capacity for delivering 100 to assure proper emergency management response. percent, and never less than 30 percent, oxygen concentration at An emergency cart (kit) must be readily accessible. Emergency a flow rate appropriate to the child’s size. Additionally, inhalation equipment must be able to accommodate children of all ages and equipment must have a fail-safe system that is checked and calibrated sizes. It should include equipment to resuscitate a non-breathing, regularly according to the practitioner’s state laws and regulations. An unconscious patient and provide continuous support until trained in-line oxygen analyzer must be used if nitrous oxide/oxygen delivery emergency personnel arrive. A positive pressure oxygen delivery equipment is capable of delivering more than 70 percent nitrous oxide system capable of administering greater than 90 percent oxygen at a and less than 30 percent oxygen. Equipment must have an appropriate 10 liters/minute flow for at least 60 minutes (650 liters, “E” cylinder) scavenging system (see below). must be available. When a self-inflating bag valve mask device is The practitioner who utilizes nitrous oxide/oxygen analgesia/anxiolysis used for delivering positive pressure oxygen, a 15 liters/minute flow for a pediatric dental patient must possess appropriate training and is recommended. There should be documentation that all emergency skills and have available the proper facilities, personnel and equipment equipment and drugs are checked and maintained on a regularly to manage any reasonably foreseeable emergency. Training and scheduled basis. Where state law mandates equipment and facilities, certification in basic life support are required for all clinical personnel. such statutes should supersede this guideline.

Occupational safety In an effort to reduce occupational health hazards associated with use of effective scavenging systems and periodic evaluation and nitrous oxide, the American Academy of Pediatric Dentistry (AAPD) maintenance of the delivery and scavenging systems. recommends exposure to ambient nitrous oxide be minimized through

Anesthesia personnel and administration This section is meant to assist the dental practitioner who elects to use delivery equipment, appropriate monitors and emergency anesthesia personnel for the administration of deep sedation/general equipment, and medications. anesthesia for pediatric dental patients in a dental office or other 4. Appropriate documentation on the procedure, including: facility outside of an accredited hospital or surgicenter. It describes the ○○ Rationale for sedation/general anesthesia. necessary personnel, facilities, documentation and quality assurance ○○ Informed consent. mechanisms required to provide optimal and responsible pediatric ○○ Instructions to parent. patient care. It considers the following interventions and practices: ○○ Dietary precautions. 1. Training and credentialing of anesthesia personnel for office-based ○○ Preoperative health evaluation. deep sedation/general anesthesia procedures. ○○ Medication prescriptions. 2. Training of the office staff in emergency procedures. ○○ Vital signs. 3. Provision of appropriate facilities that comply with applicable ○○ Recovery. laws, codes and regulations including dental equipment, anesthesia 5. Risk management and quality assurance.

Personnel Office-based deep sedation/general anesthesia techniques require at ●● The anesthesia care provider must be a licensed dental or medical least three individuals. The anesthesia care provider’s responsibilities practitioner with appropriate and current state certification for deep are to administer drugs, or direct their administration, and vigilantly sedation/general anesthesia. observe the patient’s vital signs, airway patency, cardiovascular and ●● The anesthesia care provider must have completed a one- or two- neurological status, and adequacy of ventilation. In addition to the year dental anesthesia residency or its equivalent, as approved by anesthesia care provider, the operating dentist and other staff must be the American Dental Association (ADA), or medical anesthesia trained in emergency procedures. residency, as approved by the American Medical Association It is the obligation of treating practitioners when employing anesthesia (AMA). personnel to administer deep sedation/general anesthesia to verify their ●● The anesthesia care provider currently must be licensed by and in credentials and experience, including: compliance with the laws of the state in which he or she practices. Laws vary from state to state and may supersede any portion of this document.

Page 120 Dental.EliteCME.com ●● If state law permits a certified registered nurse anesthetist or ●● The anesthesia care provider explains potential risks and obtains anesthesia assistant to function under the supervision of a dentist, informed consent for sedation/anesthesia. the dentist is required to have completed training in deep sedation/ Office staff members should understand their additional general anesthesia and be licensed or permitted, as appropriate to responsibilities and special considerations (e.g., loss of protective state law. reflexes) associated with office-based deep sedation/general anesthesia. The dentist and anesthesia care provider must be compliant with the Advanced training in recognition and management of pediatric American Academy of Pediatrics/American Academy of Pediatric emergencies is critical in providing safe sedation and anesthetic care. Dentistry (AAP/AAPD)’s Guideline on Monitoring and Management Although it is appropriate for the most experienced professional of Pediatric Patients During and After Sedation for Diagnostic and (i.e., the anesthesia provider) to assume responsibility in managing Therapeutic Procedures or other appropriate guidelines of the ADA, anesthesia-related emergencies, the operating dentist and clinical staff AMA and their recognized specialties. The recommendations in need to maintain current expertise in basic life support. this document may be exceeded at any time if the change involves An individual experienced in recovery care must be in attendance in improved safety and is evidence-based or supported by currently the recovery facility until the patient, through continual monitoring, accepted practice. exhibits respiratory and cardiovascular stability and appropriate The dentist and anesthesia personnel must work together to increase discharge criteria have been met. patient safety. Effective communication is essential: In addition, the staff of the treating dentist must be well-versed ●● The dentist introduces the concept of deep sedation/general in rescue and emergency protocols (including cardiopulmonary anesthesia to the parent and provides appropriate preoperative resuscitation) and have contact numbers for emergency medical instructions and informational materials. services and ambulance services. Emergency preparedness must be ●● The dentist or his or her designee coordinates medical updated and practiced on a regular basis. consultations when necessary.

Facilities A continuum exists that extends from wakefulness across all levels of For deep sedation, there shall be continuous monitoring of oxygen sedation. Often these levels are not easily differentiated, and patients saturation and heart rate and intermittent time-based recording of may drift through them. When anesthesia care providers are used for respiratory rate and blood pressure. When adequacy of ventilation office-based administration of deep sedation or general anesthesia, is difficult to observe, use of a precordial stethoscope or capnograph the facilities in which the dentist practices must meet the guidelines is encouraged. An electrocardiographic monitor should be readily and appropriate local, state and federal codes for administration of the available for patients undergoing deep sedation. In addition to the deepest possible level of sedation/anesthesia. monitors previously mentioned, a temperature monitor and pediatric Facilities also should comply with applicable laws, codes and defibrillator are required for general anesthesia. regulations on controlled drug storage, fire prevention, building Emergency equipment must be readily accessible and should include construction and occupancy, accommodations for the disabled, suction, drugs necessary for rescue and resuscitation (including 100 occupational safety and health, and disposal of medical waste and percent oxygen capable of being delivered by positive pressure at hazardous waste. The treatment room must accommodate the dentist appropriate flow rates for up to one hour), and age-/size-appropriate and auxiliaries, the patient, the anesthesia care provider, the dental equipment to resuscitate and rescue a nonbreathing or unconscious equipment, and all necessary anesthesia delivery equipment along with pediatric dental patient and provide continuous support while the appropriate monitors and emergency equipment. Expeditious access to patient is being transported to a medical facility. The treatment facility the patient, anesthesia machine (if present), and monitoring equipment should have medications, equipment and protocols available to treat should be available at all times. malignant hyperthermia when triggering agents are used. Recovery Because laws and codes vary from state to state, guidelines presented facilities must be available and suitably equipped. Backup power in this chapter should be followed as the minimum requirements. sufficient to ensure patient safety should be available in case of an emergency.

Documentation Before delivery of deep sedation/general anesthesia, patient safety 99 Recovery: The condition of the patient, that discharge criteria have requires that appropriate documentation shall address rationale been met, time of discharge, and into whose care the discharge for sedation/general anesthesia, informed consent, instructions to occurred must be documented. Requiring the signature of the parent, dietary precautions, preoperative health evaluation, and responsible adult to whom the child has been discharged, verifying any prescriptions along with the instructions given for their use. that he or she has received and understands the post-operative Documentation requires a time-based anesthesia record, including: instructions, is encouraged. 99 Vital signs: Pulse and respiratory rates, blood pressure and oxygen While various business/legal arrangements may exist between the saturation must be monitored and recorded at least every five treating dentist and the anesthesia provider, the dental staff must minutes throughout the procedure and at specific intervals until the maintain all patient records, including time-based anesthesia records, patient has met documented discharge criteria. taking place in the facility, so they are readily available if needed. The 99 Drugs: Name, dose, route, site, time of administration and patient dentist must assure that the anesthesia provider also maintains patient effect of all drugs, including local anesthesia, must be documented. records that are readily available. When anesthetic gases are administered, inspired concentration and duration of inhalation agents and oxygen shall be documented.

Risk management and quality assurance Dentists who use in-office anesthesia care providers must take (ASA) physical status classification. Knowledge, preparation and all necessary measures to minimize risk to patients. The dentist communication between professionals are essential. Before subjecting must be familiar with the American Society of Anesthesiologists a patient to deep sedation/general anesthesia, the patient must undergo

Dental.EliteCME.com Page 121 a preoperative health evaluation. High-risk patients should be treated Unexpected or negative outcomes must be reviewed to monitor the in a facility properly equipped to provide for their care. The dentist quality of services provided. This will decrease risk, allow for open and anesthesia care provider must communicate during treatment and frank discussions, document risk analysis and intervention, and to share concerns about the airway or other details of patient safety. improve the quality of care for the pediatric dental patient. Furthermore, they must work together to develop and document mechanisms of quality assurance.

Local anesthesia use and the child patient Guidelines in this section, revised in 2009 by the American ○○ The anticipated duration of the dental procedure. Association of Pediatric Dentists, are intended to help practitioners ○○ The need for hemorrhage control. make decisions when using local anesthesia to control pain in pediatric ○○ The planned administration of other agents (e.g., nitrous oxide, patients and individuals with special health care needs during the sedative agents, general anesthesia). delivery of oral health care. It considers the following interventions ○○ The practitioner’s knowledge of the anesthetic agent. and practices: ●● Use of vasoconstrictors in local anesthetics is recommended to 1. Topical anesthetics, such as lidocaine and benzocaine. decrease the risk of toxicity of the anesthetic agent, especially 2. Injectable local anesthetics and vasoconstrictors: when treatment extends to two or more quadrants in a single visit. ○○ Lidocaine. ●● In cases of bisulfate allergy, use of a local anesthetic without ○○ Mepivacaine. vasoconstrictor is indicated. Local anesthetic without ○○ Articaine. vasoconstrictor also can be used for shorter treatment needs but ○○ Prilocaine. should be used with caution to minimize the risk of toxicity of the ○○ Bupivacaine. anesthetic agents. ○○ Epinephrine. ●● The established maximum dosage for any anesthetic should not be ○○ Norepinephrine. exceeded. ○○ Levonordefrin. Documentation of local anesthesia 3. Selection of syringes and needles. 99 Documentation must include the type and dosage of local 4. Documentation of local anesthesia administration. anesthetic. Dosage of vasoconstrictors, if any, must be noted (e.g., 5. Supplemental injection techniques: 34 mg lidocaine with 0.017 mg epinephrine or 34 mg lidocaine ○○ Computer-controlled local anesthetic delivery. with 1:100,000 epinephrine). ○○ Periodontal injection techniques (i.e., periodontal ligament 99 Documentation may include the type of injections given (e.g., [PDL], intraligamentary and peridental injection). infiltration, block, intraosseous), needle selection and patient’s ○○ “Needleless” systems. reaction to the injection. ○○ Intraseptal or intrapulpal injection. 99 If the local anesthetic was administered in conjunction with 6. Emergency and complication management. sedative drugs, the doses of all agents must be noted on a time- 7. Administration of local anesthesia with sedation, general based record. anesthesia or nitrous oxide/oxygen analgesia/anxiolysis. 99 In patients for whom the maximum dosage of local anesthetic may The following recommendations are best practices for administering be a concern, the weight should be documented preoperatively. anesthetic agents: 99 Documentation should include that post-injection instructions were Topical anesthetics reviewed with the patient and parent. ●● Topical anesthetic may be used before the injection of a local Local anesthetic complications anesthetic to reduce discomfort associated with needle penetration. * Practitioners who utilize any type of local anesthetic in a pediatric ●● The pharmacological properties of the topical agent should be dental patient must possess appropriate training and skills and have understood. available the proper facilities, personnel and equipment to manage ●● A metered spray is suggested if an aerosol preparation is selected. any reasonably foreseeable emergency. ○○ Systemic absorption of the drugs in topical anesthetics must * Care should be taken to ensure proper needle placement during the be considered when calculating the total amount of anesthetic intraoral administration of local anesthetics. Practitioners should administered. aspirate before every injection and inject slowly. Selection of syringes and needles * After the injection, the doctor, hygienist or assistant should remain ●● For the administration of local dental anesthesia, dentists with the patient while the anesthetic begins to take effect. should select aspirating syringes that meet the American Dental * Residual soft tissue anesthesia should be minimized in pediatric Association (ADA) standards. and special health care needs patients to decrease risk of self- ●● Short needles may be used for any injection in which the thickness inflicted post-operative injuries. of soft tissue is less than 20 mm. A long needle must be used * Practitioners should advise patients and their caregivers about for a deeper injection into soft tissue. Any 23- through 30-gauge appropriate behavioral precautions (e.g., do not bite or suck on needle may be used for intraoral injections because blood can be lip or cheek, do not ingest hot substances) and the possibility of aspirated through all of them. Aspiration can be more difficult, soft tissue trauma following the administration of local anesthesia. however, when smaller-gauge needles are used. An extra-short, Placing a cotton roll in the mucobuccal fold may help prevent 30-gauge is appropriate for infiltration injections. injury, and lubricating the lips with petroleum jelly helps prevent ●● Needles should not be bent if they are to be inserted into soft drying. Practitioners who use phentolamine mesylate injections tissue to a depth of greater than 5 mm or inserted to their hub for to reduce the duration of local anesthesia still should follow these injections to avoid needle breakage. recommendations. Injectable local anesthetic agents ●● Selection of local anesthetic agents should be based upon: ○○ The patient’s medical history and mental/developmental status.

Page 122 Dental.EliteCME.com Supplemental injections to obtain local anesthesia Alternative techniques for the delivery of local anesthesia may be * If a local anesthetic is injected into an area of infection, its onset considered to minimize the dose of anesthetic used, improve patient will be delayed or even prevented. Inserting a needle into an active comfort, and improve successful dental anesthesia. Local anesthesia site of infection may also lead to possible spread of the infection. can be combined with sedation, general anesthesia and nitrous oxide/ * Local anesthetics without vasoconstrictors should be used with oxygen analgesia/anxiolysis with the following provisos: caution because of rapid systemic absorption, which may result in ●● Particular attention should be paid to local anesthetic doses used overdose. in children. To avoid excessive doses for the patient who is going * Compounded topical anesthetics contain high doses of both amide to be sedated, a maximum recommended dose based upon weight and ester agents and are at risk for side effects. The U.S. Food should be calculated. and Drug Administration does not regulate compounded topical ●● The dosage of local anesthetic should not be altered if nitrous anesthetics and recently issued a warning about their use. oxide/oxygen analgesia/anxiolysis is administered. * While rare, needle breakage is a potential risk that occurs most ●● When general anesthesia is employed, local anesthesia may be commonly when a needle is weakened by being bent before used to reduce the maintenance dosage of the anesthetic drugs. insertion into the soft tissues, or in some cases, by patient The anesthesiologist should be informed of the type and dosage of movement after the needle has been inserted. the local anesthetic used. Recovery room personnel also should be Contraindications informed. XX Epinephrine is contraindicated in hyperthyroid patients. Potential benefits XX Levonordefrin and norepinephrine are absolutely contraindicated ++ Appropriate use of local anesthesia in pediatric patients and in patients receiving tricyclic antidepressants because patients with special health care needs prevents pain during dental dysrhythmias may occur (epinephrine dose should be kept to a procedures, builds trust, allays fear and anxiety, and promotes a minimum). positive dental attitude. XX Absolute contraindications for local anesthetics include a Potential risks documented local anesthetic allergy (allergy to one amide does not * Side effects and toxicities of local anesthetics, epinephrine and rule out the use of another amide, but allergy to one ester rules out levonordefrin include central nervous system and cardiovascular use of another ester). toxicity during overdose, allergic reactions, paresthesia and XX A bisulfate preservative is used in local anesthetics containing postoperative soft tissue injury. epinephrine. For patients with an allergy to bisulfates, use of a * An end product of prilocaine metabolism can induce formation local anesthetic without vasoconstrictor is indicated. of methemoglobin, reducing the oxygen carrying capacity of XX Intraosseous techniques may be contraindicated with primary teeth the blood. In patients with subclinical methemoglobinemia or because of potential for damage to developing permanent teeth. with toxic doses (greater than 6mg/kg), prilocaine can induce XX The use of the periodontal ligament injection or intraosseous methemoglobinemia symptoms (e.g., gray or slate blue cyanosis methods is contraindicated in the presence of inflammation or of lips, mucous membranes and nails; respiratory and circulatory infection at the injection site. distress). XX Prilocaine may be contraindicated in patients with * Accidental lip or cheek trauma can occur. methemoglobinemia, sickle cell anemia, anemia, or symptoms of hypoxia or in patients receiving acetaminophen or phenacetin because both medications elevate methemoglobin levels.

Caries risk-assessment and management in the child patient Guidelines on dental caries were revised in 2010 to better help fluoride, dietary and restorative protocols, based upon caries risk and physicians making treatment and diagnostic decisions on prophylaxis, patient compliance.

Data supporting revised recommendations Current caries management protocol is based on results of clinical Guideline Network (SIGN) guideline for the management of caries trials, systematic reviews and expert panel recommendations providing in pre-school children, a Maternal and Child Health Bureau Expert extensive information about diagnostic, preventive and restorative Panel, and the CDC’s fluoride guidelines. treatments. The information presented here comes from the following ●● Guidelines for pit and fissure sealants are based on ADA’s Council sources: on Scientific Affairs recommendations for the use of pit-and- ●● Radiographic diagnostic guidelines are based on the latest fissure sealants. guidelines from the American Dental Association (ADA). ●● Guidelines for the use of xylitol are based on the American ●● Systemic fluoride protocols are based on the Centers for Disease Academy of Pediatric Dentistry (AAPD) oral health policy on use Control and Prevention (CDC) recommendations for using of xylitol in caries prevention, a clinical trial on high caries-risk fluoride. infants and toddlers, and two evidence-based reviews. ●● Guidelines for the use of topical fluoride treatment are based on When data did not appear sufficient or were inconclusive, the ADA’s Council on Scientific Affairs’ recommendations for recommendations were based upon expert or consensus opinion by professionally applied topical fluoride, the Scottish Intercollegiate experienced researchers and clinicians.

Prophylaxis Periodic professional prophylaxis should be performed to: ●● Remove extrinsic stain. ●● Instruct the caregiver and child or adolescent in proper oral ●● Facilitate the examination of hard and soft tissues. hygiene techniques. ●● Introduce dental procedures to the young child and apprehensive ●● Remove microbial plaque and calculus. patient. ●● Polish hard surfaces to minimize the accumulation and retention of plaque.

Dental.EliteCME.com Page 123 In addition to establishing the need for a prophylaxis, the clinician techniques and removing plaque, stain, calculus and the factors that should determine the most appropriate type of prophylaxis for each influence their build-up. patient. The practitioner should select the least aggressive technique Potential benefits that fulfills the goals of the procedure. To minimize loss of the ++ An individualized preventive plan increases the probability of fluoride-rich layer of enamel during polishing, the least abrasive paste good oral health by demonstrating proper oral hygiene methods should be used with light pressure. If a rubber cup/pumice prophylaxis and techniques and removing plaque, stain, calculus, and the is performed, a topical fluoride application is recommended. factors that influence their build-up. A patient’s risk for caries/periodontal disease, as determined by the Potential risks patient’s dental provider, should help determine the interval of the * The use of abrasive toothpastes and whitening products as well as prophylaxis. Patients who exhibit higher risk for developing caries or abrasion during a prophylaxis can remove the acquired pellicle. periodontal disease should have recall visits at intervals more frequent This can have an adverse effect on exposed tooth surfaces by than every six months. This allows increased professional fluoride increasing the chances of enamel loss through exposure to dietary therapy application, microbial monitoring, antimicrobial therapy acids. Furthermore, even though the pellicle begins forming reapplication, and re-evaluating behavioral changes for effectiveness. immediately after it is removed, it may take up to seven days, An individualized preventive plan increases the probability of good possibly longer, to mature fully and offer maximal protection oral health by demonstrating proper oral hygiene methods and against dietary acid.

Xylitol and caries prevention This section provides information to help oral health care professionals Clinicians may consider recommending xylitol use to moderate or high make informed decisions about the use of xylitol-based products in caries-risk patients. Those recommending xylitol should be familiar caries prevention for infants, children and adolescents with moderate with the product labeling and recommend age-appropriate products. or high caries risk. They should routinely reassess (not less than once every six months) a patient for changes in caries-risk status and adjust recommendations accordingly.

Dosage There is accumulating evidence that total daily doses of 3 to 8 grams grams per day. Although tables of clinically effective xylitol containing of xylitol are required for a clinical effect with the currently available products have recently been published, the products are continually delivery methods of syrup, chewing gum and lozenges. Dosing changing. frequency should be a minimum of two times a day, not to exceed 8 Table I: Benefits of prophylaxis options

Plaque removal Stain Calculus Polish/smooth Education of patient/parent Facilitate exam Toothbrush Yes No No No Yes Yes Power brush Yes Yes No No Yes Yes Rubber cup Yes Yes No Yes Yes Yes Hand instruments Yes Yes Yes No Yes Yes Current evidence supports the following recommendations for children at moderate or high caries risk: Table II: Recommended xylitol dosage for children with moderate or high caries risk Age Xylitol product Dosage Less than 4 years old Xylitol syrup* 3-8 grams/day in divided doses 4 years old or greater Age appropriate products such as chewing gum**, mints, lozenges, snack foods 3-8 grams/day in divided doses such as gummy bears. Key to Table II *The American Academy of Pediatrics does not recommend chewing gum use in children less than 4 years of age due to the risk of choking. **The American Academy of Pediatrics does not recommend chewing gum use in children less than 4 years of age because of the risk of choking. Modality Chewing gum has been the predominant modality for xylitol delivery even milk have been studied as delivery vehicles, but they are neither in clinical studies. Studies that have used xylitol-containing mints and well established scientifically nor available commercially at present. hard candies have shown them to be as effective as xylitol-containing A pacifier with a pouch containing slow release xylitol in tablet form, chewing gum. The American Academy of Pediatrics (AAP) does not not yet available in the United States, has shown high salivary xylitol recommend use of chewing gum, mints, or hard candy by children less concentrations and may be a potential delivery vehicle for infants. than 4 years of age because of the risk of choking. Currently, xylitol-containing chewing gum, mints, energy bars and A randomized trial of xylitol syrup (8 g/day) reduced early childhood foods, nasal sprays and oral hygiene products (e.g., mouth rinse, caries by 50 to 70 percent in children 15 to 25 months of age. Another gels, wipes, floss) are commercially available through retail or online study showed that gum or lozenges consumed by children at 5 venues. However, they may not contain the necessary therapeutic level grams total dose per day at about age 10 resulted in 35 to 60 percent xylitol as the only sweetener, or adequate labeling. reductions of tooth decay, with no differences between the delivery Studies using toothpaste formulations with 10 percent xylitol (dose methods. Xylitol-containing gummy bears, other confections and of 0.1 g/brushing) have shown reduction in mutans streptococci (MS)

Page 124 Dental.EliteCME.com levels and caries in children. The toothpastes that were studied are Potential benefits not for sale in the United States. Furthermore, the xylitol-containing ++ Decrease in caries rates, increment or onset. toothpastes that currently are sold in the United States have never been ++ Maternal consumption of xylitol may reduce the acquisition of tested and their formulas differ from those tested. mutans streptococci (MS) and dental caries by their children.

Side effects Parents need to control the amount of xylitol and other polyols that These symptoms usually occur at higher dosages and will subside once their child consumes. Xylitol is safe for children when consumed in xylitol consumption is stopped. To minimize gas and diarrhea, xylitol therapeutic doses for dental caries prevention. Common side effects should be introduced slowly, over a week or more, to acclimate the that may occur with the use of xylitol are gas and osmotic diarrhea. body to the polyol, especially in young children.

Limitations of caries risk assessment guidelines Risk assessment procedures used in medical practice do not have medical providers. Tables III a, III b, and III c are examples of sufficient data to accurately quantitate a person’s disease susceptibility caries management protocols. and allow for preventive measures. Guidelines must recognize that ●● While there is not enough information at present to have treatment can and should be tailored to fit individual needs, depending quantitative caries-risk assessment analyses, estimating children on the patient, practitioner, setting and other factors. Deviations from at low, moderate and high caries risk by a preponderance of risk guidelines may occur and can be justified by differences in individual and protective factors will enable a more evidence-based approach circumstances. Guidelines are designed to produce optimal outcomes, to medical provider referrals as well as establish periodicity and not minimal standards of practice. intensity of diagnostic, preventive, and restorative services. In summary: ●● Clinical management protocols based on a child’s age, caries risk ●● Dental-caries risk assessment, based on a child’s age, biological and level of patient/parent cooperation provide health providers factors, protective factors and clinical findings, should be a routine with criteria and protocols for determining the types and frequency component of new and periodic examinations by oral health and of diagnostic, preventive and restorative care for patient specific management of dental caries. Table IIIa: Sample caries management protocol for 1-2-year-olds

Risk category Diagnostics Interventions Restorative Fluoride Diet Low risk Recall every 6-12 months Twice daily brushing Counseling Surveillance× Baseline mutans streptococci (MS)α Moderate risk, Recall every 6 months Twice daily brushing with fluoridated Counseling Active surveillance€ of incipient parent engaged Baseline MSα toothpasteβ lesions Fluoride supplementsd Professional topical treatment every 6 months Moderate risk, Recall every 6 months Twice daily brushing with fluoridated Counseling, Active surveillance€ of incipient parent not Baseline MSα toothpasteβ with limited lesions engaged Professional topical treatment every expectations 6 months High risk, Recall every 3 months Twice daily brushing with fluoridated Counseling Active surveillance€ of incipient parent engaged Baseline and follow up MSα toothpasteβ lesions Fluoride supplementsd Restore cavitated lesions with Professional topical treatment every interim therapeutic restorations 3 months (ITR)¢ or definitive restorations High risk Recall every 3 months Twice daily brushing with fluoridated Counseling, Active surveillance€ of incipient parent not Baseline and follow up MSα toothpasteβ with limited lesions engaged Professional topical treatment every expectations Restore cavitated lesions with 3 months interim therapeutic restorations¢ or definitive restorations

Dental.EliteCME.com Page 125 Table IIIb: Sample caries management protocol for 3-5-year-olds

Risk category Diagnostics Interventions Restorative Fluoride Diet Sealantsλ Low risk Recall every 6-12 months Twice daily brushing with No Yes Surveillancex Radiographs every 12-24 fluoridated toothpaste¥ months Baseline MSα Moderate risk, Recall every 6 months Twice daily brushing with Counseling Yes Active surveillance€ of parent engaged Radiographs every 6-12 fluoridated toothpaste¥ incipient lesions months Fluoride supplementsd Restoration of cavitated or Baseline MSα Professional topical treatment enlarging lesions every 6 months Moderate risk, Recall every 6 months Twice daily brushing with Counseling, Yes Active surveillance€ of parent not Radiographs every 6-12 fluoridated toothpaste¥ with limited incipient lesions engaged months Professional topical treatment expectations Restoration of cavitated or Baseline MSα every 6 months enlarging lesions High risk, Recall every 3 months Brushing with 0.5 percent Counseling Yes Active surveillance€ of parent engaged Radiographs every 6 fluoride (with caution) incipient lesions months Fluoride supplementsd Restoration of cavitated or Baseline and follow up Professional topical treatment enlarging lesions MSα every 3 months High risk Recall every 3 months Brushing with 0.5 percent Counseling, Yes Restore incipient, cavitated, parent, not Radiographs every 6 fluoride with limited or enlarging lesions engaged months Professional topical treatment expectations Baseline and follow up MSα every 3 months Table IIIc: Sample caries management protocol for 6-year-olds and above

Risk category Diagnostics Interventions Restorative Fluoride Diet Sealantsλ Low risk Recall every 6-12 months Twice daily brushing with fluoridated No Yes Surveillancex Radiographs every 12-24 toothpasteµ months Moderate risk Recall every 6 months Twice daily brushing with fluoridated Counseling Yes Active surveillance€ of patient/parent Radiographs every 6-12 toothpasteµ incipient lesions engaged months Fluoride supplementsd Restoration of cavitated or Professional topical treatment every 6 enlarging lesions months Moderate risk Recall every 6 months Twice daily brushing with toothpasteµ Counseling, Yes Active surveillance€ of patient/parent Radiographs every 6-12 Professional topical treatment every 6 with limited incipient lesions not engaged months months expectations Restoration of cavitated or enlarging lesions High risk Recall every 3 months Brushing with 0.5 percent fluoride Counseling Yes Active surveillance€ of patient/parent Radiographs every 6 Fluoride supplementsd Xylitol incipient lesions engaged months Professional topical treatment every 3 Restoration of cavitated or months enlarging lesions High risk Recall every 3 months Brushing with 0.5 percent fluoride Counseling, Yes Restore incipient, cavitated, patient/parent Radiographs every 6 Professional topical treatment every 3 with limited or enlarging lesions not engaged months months expectations Xylitol Key for Tables IIIa,b, and c α Salivary mutans streptococci bacterial levels. β Parental supervision of a “smear” amount of toothpaste. x Periodic monitoring for signs of caries progression. d Need to consider fluoride levels in drinking water. € Careful monitoring of caries progression and prevention program. ¢ Interim therapeutic restoration. ¥ Parental supervision of a “pea-sized” amount of toothpaste. λ Indicated for teeth with deep fissure anatomy or developmental defects. μ Less concern about the quantity of toothpaste.

Page 126 Dental.EliteCME.com Restorative dentistry and the child patient This section addresses techniques and materials used to treat infants, Restorative treatment is based upon the results of an appropriate clinical children and adolescents with tooth damage from dental caries or examination and is ideally part of a comprehensive treatment plan, traumatic injury, or with dental developmental defects requiring prepared in conjunction with an individually-tailored preventive program. restoration. It will consider success rates (wear resistance, aesthetics, The treatment plan must take the following factors into consideration: strength, function, reduction of sensitivity) for the following ●● Developmental status of the dentition. restorative procedures: ●● Caries-risk assessment. ●● Use of dentin/enamel adhesives. ●● Patient’s oral hygiene. ●● Use of glass ionomer cements. ●● Anticipated parental compliance and likelihood of timely recall. ●● Use of highly-filled resin-based composites. ●● Patient’s ability to cooperate for treatment. ●● Amalgam restorations. ●● Stainless steel crown (SSC) restorations. Tooth preparation should include the removal of caries or improperly ●● Labial resin restoration. developed tooth structure to establish appropriate outline, resistance, ●● Porcelain veneer restoration. retention, and convenience form compatible with the restorative ●● Full-cast metal crown restorations. material to be utilized. Rubber-dam isolation should be utilized when ●● Porcelain-fused-to-metal crown restorations. possible during the preparation and placement of restorative materials. ●● Fixed prosthetic restorations. Restorative treatment can repair or limit the damage from dental ●● Removable prosthetic appliances. caries, protect and preserve the tooth structure, re-establish adequate Pit-and-fissure sealants will be addressed in the next section. function, restore aesthetics (where applicable), and provide ease in maintaining good oral hygiene. Pulp vitality should be maintained wherever possible. Table IV: Best practices for restorative procedures Restorative procedure Best practices Dentin/enamel The dental literature supports the use of tooth bonding adhesives, when used according to the adhesives manufacturer’s instruction unique for each product, as being effective in primary and permanent teeth in enhancing retention of restorations, minimizing microleakage, and reducing sensitivity. Glass ionomer Glass ionomers cements can be recommended as: cements ++ Luting cements ++ Cavity base and liner ++ Class I, II, III, and V restorations in primary teeth ++ Class III and V restorations in permanent teeth in high risk patients or teeth that cannot be isolated ++ Caries control with: ○○ High-risk patients ○○ Restoration repair ○○ Interim therapeutic restorations (ITR) ○○ Alternative (atraumatic) restorative technique (ART) Resin-based Indications composites Resin-based composites are indicated for: ++ Class I pit-and-fissure caries where conservative preventive resin restorations are appropriate ++ Class I caries extending into dentin ++ Class II restorations in primary teeth that do not extend beyond the proximal line angles ++ Class II restorations in permanent teeth that extend approximately one third to one half the buccolingual intercuspal width of the tooth ++ Class III, IV, V restorations in primary and permanent teeth ++ Strip crowns in the primary and permanent dentitions Contraindications Resin-based composites are not the restorations of choice in the following situations: XX Where a tooth cannot be isolated to obtain moisture control XX In individuals needing large multiple surface restorations in the posterior primary dentition XX In high-risk patients who have multiple caries and/or tooth demineralization and who exhibit poor oral hygiene and compliance with daily oral hygiene, and when maintenance is considered unlikely Amalgam restorations Dental amalgam is recommended for: ++ Class I restorations in primary and permanent teeth ++ Class II restorations in primary molars where the preparation does not extend beyond the proximal line angles ++ Class II restorations in permanent molars and premolars ++ Class V restorations in primary and permanent posterior teeth Stainless steel crown SSC restoration is recommended for: (SSC) restoration ●● Children at high risk exhibiting anterior tooth caries and/or molar caries may be treated with SSCs to protect the remaining at-risk tooth surfaces. ●● Children with extensive decay, large lesions, or multiple-surface lesions in primary molars should be treated with SSCs. ●● Strong consideration should be given to the use of SSCs in children who require general anesthesia.

Dental.EliteCME.com Page 127 Labial resin or Veneers may be indicated for the restoration of anterior teeth with fractures, developmental defects, intrinsic porcelain veneer discoloration, and/or other aesthetic conditions. restoration Full-cast or porcelain- Full-cast metal crowns or porcelain-fused-to-metal crown restorations may be utilized in permanent teeth that are fully fused-to-metal crown erupted and the gingival margin is at the adult position for: restoration ++ Teeth having developmental defects, extensive carious or traumatic loss of structure, or endodontic treatment ++ As an abutment for fixed prostheses ++ For restoration of single-tooth implants Fixed prosthetic Fixed prosthetic restorations to replace one or more missing teeth may be indicated to: restorations for ++ Establish aesthetics missing teeth ++ Maintain arch space or integrity in the developing dentition ++ Prevent or correct harmful habits ++ Improve function Removable prosthetic Removable prosthetic appliances may be indicated in the primary, mixed, or permanent dentition when teeth are appliances missing. Removable prosthetic appliances may be utilized to: ++ Maintain space ++ Obturate congenital or acquired defects ++ Establish aesthetics or occlusal function ++ Facilitate infant speech development or feeding Table V: Pit-and-fissure sealant recommendations Topic Recommendation Caries prevention Sealants should be placed in pits and fissures of children’s primary teeth when it is determined that the tooth, or the patient, is at risk of developing caries*† Sealants should be placed on pits and fissures of children’s and adolescents’ permanent teeth when it is determined that the tooth, or the patient, is at risk of developing caries*† Noncavitated carious Pit-and-fissure sealants should be placed on early (noncavitated) carious lesions, as defined in this document, in lesions‡ children, adolescents and young adults to reduce the percentage of lesions that progress† Resin-based versus Resin-based sealants are the first choice of material for dental sealants glass ionomer cement Glass ionomer cement may be used as an interim preventive agent when there are indications for placement of a resin- based sealant but concerns about moisture control may compromise such placement§ Placement techniques A compatible one-bottle bonding agent, which contains both an adhesive and a primer, may be used between the previously acid-etched enamel surface and the sealant material when, in the opinion of the dental professional, the bonding agent would enhance sealant retention in the clinical situation§ Use of available self-etching bonding agents, which do not involve a separate etching step, may provide less retention than the standard acid-etching technique and is not recommended Routine mechanical preparation of enamel before acid etching is not recommended When possible, a four-handed technique should be used for placement of resin-based sealants When possible, a four-handed technique should be used for placement of glass ionomer cement sealants The oral health care professional should monitor and reapply sealants as needed to maximize effectiveness Key to Table V * Change in caries susceptibility can occur. It is important to consider that the risk of developing dental caries exists on a continuum and changes across time as risk factors change. Therefore, clinicians should re-evaluate each patient’s caries risk status periodically. † Clinicians should use recent radiographs, if available, in the decision-making process, but should not obtain radiographs for the sole purpose of placing sealants. Clinicians should consult the American Dental Association/U.S. Food and Drug Administration guidelines on selection criteria for dental radiographs. ‡ “Noncavitated carious lesion” refers to pits and fissures in fully erupted teeth that may display discoloration not due to extrinsic staining, developmental opacities or fluorosis. The discoloration may be confined to the size of a pit or fissure or may extend to the cusp inclines surrounding a pit or fissure. The tooth surface should have no evidence of a shadow indicating dentinal caries, and, if radiographs are available, they should be evaluated to determine that neither the occlusal nor the proximal surfaces have signs of dentinal caries. § These clinical recommendations offer two options for situations in which moisture control, such as with a newly erupted tooth at risk of developing caries, patient compliance, or both, are a concern. These options include use of a glass ionomer cement material or use of a compatible one-bottle bonding agent, which contains both an adhesive and a primer. Clinicians should use their expertise to determine which technique is most appropriate for an individual patient. ¶ Clinicians should consult with the manufacturer of the adhesive and/or sealant to determine material compatibility.

Page 128 Dental.EliteCME.com Pit-and-fissure sealants These clinical recommendations on pit-and-fissure sealants, published Manufacturers’ instructions for sealant placement should be consulted, in 2008 and summarized in Table V, may be useful when considered and a dry field should be maintained during placement. along with the specific characteristics of the case and patient to Potential benefits facilitate clinical decision-making. ++ Appropriate use may help prevent dental caries. Dentists are encouraged to employ caries risk assessment strategies to Potential risks determine whether placement of pit-and-fissure sealants is indicated as * A transient amount of bisphenol-A (BPA) may be detected in the a primary preventive measure. The risk of experiencing dental caries saliva of some patients immediately after initial application of exists on a continuum and changes across time as risk factors change. certain sealants as a result of the action of salivary enzymes on Therefore, caries risk status should be re-evaluated periodically. It bisphenol-dimethacrylate, a component of some sealant materials. includes the following steps: According to research, systemic BPA has not been detected as a Evaluation/risk assessment result of the use of such sealants, and potential estrogenicity at 1. Tooth cleaning and drying. such low levels of exposure has not been documented. 2. Visual examination to detect early noncavitated lesions. 3. Evaluation of patient’s caries risk status. Data was inconclusive for the following techniques: 4. Recent radiographs (but only if available). ●● Two- or four-handed sealant placement technique – The panelists 5. Periodic re-evaluation of patient’s risk status. determined that the systematic reviews and newly identified Prevention studies were insufficient to determine whether use of a four- 1. Bonding agents (total and self-etch systems). handed versus a two-handed technique improves sealant retention 2. Pit-and-fissure sealants, utilizing a four-handed technique. or caries prevention. However, when possible, a four-handed ■■ Resin-based sealants (polymerized by autopolymerization, technique is recommended. photopolymerization using visible light or a combination ●● Enamel preparation techniques – The panelists determined that the of the two processes). systematic reviews and newly identified studies were insufficient ■■ Glass ionomer cements (conventional and resin-modified). to determine whether enamel preparation, including air abrasion or enameloplasty, would improve sealant retention or caries prevention.

Management of the developing dentition and occlusion in the child patient This section provides guidance for the management of the developing 3. Completion of differential diagnosis and diagnostic summary. dentition and occlusion in pediatric dentistry. It discusses the following 4. Completion of a sequential treatment plan. topics: Management/treatment Unfavorable dentofacial development 1. Habit elimination (patient/parent counseling, behavior 1. Hypodontia (congenitally missing teeth). modification techniques, myofunctional therapy, appliance 2. Supernumerary teeth (hyperdontia). therapy, or referral to other providers, such as orthodontists, 3. Ectopic eruption. psychologists, myofunctional therapists and otolaryngologists). 4. Ankylosis. 2. Tooth extraction. 5. Tooth size/arch length discrepancy and crowding. 3. Orthodontical space closing. 6. Crossbites (dental, functional, and skeletal). 4. Placement of prostheses or implants. 7. Malocclusion (class II and class III). 5. Orthodontical alignment of permanent teeth. Assessment/diagnosis 6. Impacted tooth management (elastic or metal orthodontic 1. Clinical examination: separators, distal tipping of permanent molar). ■■ Facial analysis. 7. Space maintenance and space regaining: fixed appliances ■■ Intraoral examination. (e.g., band and loop, crown and loop, passive lingual arch, ■■ Functional analysis. distal shoe, Nance appliance, transpalatal arch) and removable 2. Maintenance of diagnostic records: appliances (e.g., partial dentures, Hawley appliance, lip ■■ Extraoral and intraoral photographs. bumper, headgear). ■■ Diagnostic dental casts. 8. Crossbite correction. ■■ Intraoral and panoramic radiographs. 9. Malocclusion assessment and correction. ■■ Lateral and anterior-posterior cephalograms. 10. Other treatment modalities (interproximal reduction, ■■ Magnetic resonance imaging. restorative bonding, veneers, crowns, implants and ■■ Computed tomography. orthognathic surgery).

Clinical examination, pretreatment records, differential diagnosis, and treatment plan A thorough clinical examination, appropriate pretreatment records, ○○ Assess aesthetics and identify orthopedic and orthodontic differential diagnosis, sequential treatment plan, and progress records interventions that may improve aesthetics and resultant self- are necessary to manage any condition affecting the developing image and emotional development. dentition. ●● Intraoral examination to: Clinical examination should include: ○○ Assess overall oral health status. ●● Facial analysis to: ○○ Determine the functional status of the patient’s occlusion. ○○ Identify adverse transverse growth patterns including ●● Functional analysis to: asymmetries (maxillary and mandibular). ○○ Determine functional factors associated with the malocclusion. ○○ Identify adverse vertical growth patterns. ○○ Detect deleterious habits. ○○ Identify adverse sagittal (anteroposterior) growth patterns and ○○ Detect temporomandibular joint dysfunction, which may dental anteroposterior (AP) occlusal disharmonies. require additional diagnostic procedures.

Dental.EliteCME.com Page 129 Diagnostic records may be needed to assist in the evaluation of the ○○ Establish a baseline growth record for longitudinal assessment patient’s condition and for documentation purposes. Prudent judgment of growth and displacement of the jaws. is exercised to decide the appropriate records required for diagnosis of ●● Other diagnostic views (e.g., magnetic resonance imaging and the clinical condition. Diagnostic records may include: computed tomographic scans) for hard and soft tissue imaging as ●● Extraoral and intraoral photographs to: indicated by history and clinical examination. ○○ Supplement clinical findings with oriented facial and intraoral A differential diagnosis and diagnostic summary are completed to photographs. achieve the following objectives: ○○ Establish a database for documenting facial changes during ●● Establish the relative contributions of the dental and skeletal treatment. structures to the patient’s malocclusion. ●● Diagnostic dental casts to: ●● Prioritize problems in terms of relative severity. ○○ Assess the occlusal relationship. ●● Detect favorable and unfavorable interactions that may result from ○○ Determine arch length requirements for intra-arch tooth size treatment options for each problem area. relationships. ●● Establish short-term and long-term objectives. ○○ Determine arch length requirements for interarch tooth size ●● Summarize the prognosis of treatment for achieving stability, relationships. function and aesthetics. ○○ Determine location and extent of arch asymmetry. ●● Intraoral and panoramic radiographs to: A sequential treatment plan is completed to achieve the following ○○ Establish dental age. objectives: ○○ Assess eruption problems. ●● Establish timing priorities for each phase of therapy. ○○ Estimate the size and presence of unerupted teeth. ●● Establish proper sequence of treatments to achieve short-term and ○○ Identify dental anomalies/pathology. long-term objectives. ●● Lateral and AP cephalograms to: ●● Ensure treatment progress is assessed and biomechanical protocol ○○ Produce a comprehensive cephalometric analysis of the is updated accordingly on a regular basis. relative dental and skeletal components in the anteroposterior, vertical and transverse dimensions.

Stages of development of occlusion Primary dentition stage supernumerary, fused, geminated); tooth size and shape (peg or small Anomalies of primary teeth and eruption may not be evident/ lateral incisors); and positions (e.g., ectopic first permanent molars). diagnosable prior to eruption because the child has not presented Space analysis can be used to evaluate arch length/crowding at the for dental examination, or because a radiographic examination time of incisor eruption. is not possible in a young child. However, evaluation should be Mid-to-late mixed dentition accomplished when feasible. The objectives of evaluation include Ectopic tooth positions should be diagnosed, especially canines, identification of all anomalies of tooth number and size (as previously bicuspids and second permanent molars. noted), anterior and posterior crossbites, and presence of habits along with their dental and skeletal sequelae. Radiographs are taken with Adolescent dentition stage appropriate clinical indicators or based upon risk assessment/history. If not instituted earlier, orthodontic diagnosis and treatment should be planned for Class I crowded, Class II, and Class III malocclusions Early mixed dentition stage as well as posterior and anterior crossbites. Third molars should be Palpation for unerupted teeth should be part of every examination. monitored as to position and space and parents informed. Panoramic, occlusal and periapical radiographs as indicated at the time of eruption of the lower incisors and first permanent molars provide Early adult dentition stage diagnostic information on anomalies of tooth numbers (e.g., missing, Third molars should be evaluated. If orthodontic diagnosis has not been accomplished, recommendations should be made as necessary.

Objectives for each stage At each stage, the objectives of intervention/treatment include of high rates of growth and prevent worsened adverse dental and reducing adverse growth, preventing increasing dental and skeletal skeletal growth. disharmonies, improving aesthetics of the smile and the accompanying ●● Mid-to-late mixed dentition stage positive effects on self-image, and improving the occlusion. Intervention for ectopic teeth may include extractions and space ŠŠ Primary dentition stage maintenance to aid eruption and reduce the risk of need for Habits and posterior crossbites should be diagnosed and addressed surgical bracket placement and orthodontic traction. Intervention as early as feasible. Parents should be informed of findings of for treatment of skeletal disharmonies and crowding may be adverse growth and developing malocclusions. Interventions/ instituted at this stage. treatment can be recommended if diagnosis can be made, treatment ●● Adolescent dentition stage is appropriate and possible, and parents are supportive and desire In full permanent dentition, final orthodontic diagnosis and to have treatment done. treatment can provide the most functional occlusion. ●● Early adult dentition stage ●● Early mixed stage Third molar position or space can be evaluated and, if indicated, Treatment should address: (1) habits, (2) arch length shortage, be removed. Full orthodontic treatment should be recommended if (3) intervention for crowded incisors, (4) intervention for ectopic needed. molars and incisors, (5) holding of leeway space, (6) crossbites, and (7) adverse skeletal growth. Treatment should take advantage

Page 130 Dental.EliteCME.com Treatment considerations The developing dentition should be monitored throughout eruption. Radiographic examination, when appropriate and feasible, should This monitoring at regular clinical examinations should include accompany clinical examination. Diagnosis of anomalies of primary diagnosis of missing, supernumerary, developmentally defective and or permanent tooth development and eruption should be made to fused or geminated teeth; ectopic eruption; and space and tooth loss inform the patient’s parent and to plan and recommend appropriate secondary to caries. intervention. This evaluation is ongoing throughout the developing dentition, at all stages.

Oral habits Management of an oral habit is indicated whenever the habit is techniques, myofunctional therapy, appliance therapy, or referral to associated with unfavorable dentofacial development or adverse other providers, such as orthodontists, psychologists, myofunctional effects on child health, or when there is a reasonable indication that therapists or otolaryngologists. Use of an appliance to manage oral the oral habit will result in unfavorable sequelae in the developing habits is indicated only when the child wants to stop the habit and permanent dentition. Any treatment must be appropriate for the child’s would benefit from a reminder. development, comprehension and ability to cooperate. Habit treatment Treatment is directed toward decreasing or eliminating the habit and modalities include patient/parent counseling, behavior modification minimizing potential deleterious effects on the dentofacial complex.

Congenitally missing teeth With congenitally missing permanent maxillary incisors or mandibular For a congenitally missing premolar, the primary molar either may second premolars, the decision to extract the primary tooth and close be maintained or extracted with subsequent placement of a prosthesis the space orthodontically versus opening the space orthodontically and or orthodontically closing the space. Maintaining the primary second placing a prosthesis or implant depends on many factors. For maxillary molar may cause occlusal problems due to its larger mesiodistal laterals, the dentist may move the maxillary canine mesially and diameter compared to the second premolar. Reducing the width of use the canine as a lateral incisor or create space for a future lateral the second primary molar is a consideration, but root resorption and prosthesis or implant. Factors that influence the decision are (1) patient subsequent exfoliation may occur. age, (2) canine shape, (3) canine position, (4) child’s occlusion and In crowded arches or with multiple missing premolars, extraction amount of crowding, (5) bite depth, and (6) quality and quantity of of the primary molars can be considered, especially in mild Class bone in the edentulous area. Early extraction of the primary canine and III cases. For a single missing premolar, if maintaining the primary lateral may be needed. molar is not possible, placement of a prosthesis or implant should be Opening space for a prosthesis or implant requires less tooth considered. Consultation with an orthodontist and prosthodontist may movement, but the space needs to be maintained with an interim be required. In addition, preserving the primary tooth may be indicated prosthesis, especially if an implant is planned. Moving the canine into in certain cases. the lateral position produces little facial change, but the resultant tooth Treatment is directed toward an aesthetically pleasing occlusion that size discrepancy often does not allow a canine-guided occlusion. functions well for the patient.

Supernumerary teeth (primary, permanent, and mesiodens) Management and treatment of hyperdontia differs if the tooth is of the mesiodens reduces the likelihood that the adjacent normal primary or permanent. Primary supernumerary teeth normally are permanent incisor will erupt on its own, especially if the apex is accommodated into the arch and usually erupt and exfoliate without completed. Inverted conical supernumeraries can be harder to remove complications. Extraction of an unerupted supernumerary tooth during if removal is delayed, as they can migrate deeper into the jaw. the primary dentition usually is not done to allow it to erupt; surgical After removal of the supernumerary, clinical and radiographic follow- extraction of unerupted supernumerary teeth can displace or damage up is indicated in six months to determine whether the normal incisor the permanent incisor. is erupting. If there is no eruption after six to 12 months and sufficient Removal of a mesiodens or other permanent supernumerary incisor space exists, surgical exposure and orthodontic extrusion is needed. results in eruption of the permanent adjacent normal incisor in 75 Removal of supernumerary teeth should facilitate eruption of percent of the cases. Extraction of an unerupted supernumerary permanent teeth and encourage normal alignment. In cases where during the early mixed dentition allows for a normal eruptive force normal alignment or spontaneous eruption does not occur, further and eruption of the permanent adjacent normal incisor. Later removal orthodontic treatment is indicated.

Ectopic eruption Treatment depends on how severe the impaction appears clinically and canine bulge cannot be palpated in the alveolar process and there radiographically. For mildly impacted first permanent molars, where is radiographic overlapping of the canine with the formed root of little of the tooth is impacted under the primary second molar, elastic the lateral during the mixed dentition. Even if the impacted canine or metal orthodontic separators can be placed to wedge the permanent is diagnosed at a later age (11 to 16), if the canine is not horizontal, first molar distally. For more severe impactions, distal tipping of the extraction of the primary canine lessens the severity of the permanent permanent molar is required. Tipping action can be accomplished with canine impaction, and 75 percent will erupt. brass wires, removable appliances using springs, fixed appliances such Extraction of the first primary molar also has been reported to allow as sectional wires with open coil springs, sling shot type appliances, a eruption of first bicuspids and to assist in the eruption of the cuspids. Halterman appliance, or surgical uprighting. This need can be determined from a panoramic radiograph. Bonded Early diagnosis and treatment of impacted maxillary canines can orthodontic treatment normally is required to create space or align lessen the severity of the impaction and may stimulate eruption of the canine. Long-term periodontal health of impacted canines after the canine. Extraction of the primary canine is indicated when the orthodontic treatment is similar to non-impacted canines.

Dental.EliteCME.com Page 131 Treatment of ectopically erupting incisors depends on the etiology. Management of ectopically erupting molars, canines and incisors Extraction of necrotic or over-retained pulpally treated primary should result in improved eruptive positioning of the tooth. In cases incisors is indicated in the early mixed dentition. Removal of where normal alignment does not occur, subsequent comprehensive supernumerary incisors in the early mixed dentition will lessen ectopic orthodontic treatment may be necessary to achieve appropriate arch eruption of an adjacent permanent incisor. After incisor eruption, form and intercuspation. orthodontic treatment involving removable or banded therapy may be needed.

Ankylosis With ankylosis of a primary molar, exfoliation usually occurs crowding. Extraction of these molars can assist in resolving crowded normally. Extraction is recommended if prolonged retention of arches in complex orthodontic cases. Surgical luxation of ankylosed the primary molar is noted. If a severe marginal ridge discrepancy permanent teeth with forced eruption has been described as an develops, extraction should be considered to prevent the adjacent teeth alternative to premature extraction. from tipping and producing space loss. Replacement resorption of Treatment of ankylosis should result in the continuing normal permanent teeth usually results in the loss of the involved tooth. development of the permanent dentition. Or, in the case of replacement Mildly to moderately ankylosed primary molars without permanent resorption of a permanent tooth, appropriate prosthetic replacement successors may be retained and restored to function in arches without should be planned.

Tooth size/arch length discrepancy and crowding Treatment considerations may include: Other treatment modalities may include interproximal reduction, ●● Making space for permanent incisors to erupt and become straight restorative bonding, veneers, crowns, implants and orthognathic naturally through primary canine extraction and space/arch length surgery. maintenance. Well-timed intervention can: ●● Orthodontic alignment of permanent teeth as soon as erupted ●● Prevent crowded incisors. and feasible, expansion and correction of arch length as early as ●● Increase long-term stability of incisor positions. feasible. ●● Decrease ectopic eruption and impaction of permanent canines. ●● Utilizing holding arches in the mixed dentition until all permanent ●● Reduce orthodontic treatment time and sequelae. bicuspids and canines have erupted. ●● Improve gingival health and overall dental health. ●● Extractions of permanent teeth. ●● Maintaining patient’s original arch form.

Space maintenance It is prudent to consider space maintenance when primary teeth are lost The literature on the use of space maintainers specific to the loss of a prematurely. Factors to consider include: particular primary tooth type includes expert opinion, case reports and ●● Specific tooth lost. details of appliance design. Treatment modalities may include: ●● Time elapsed since tooth loss. ●● Fixed appliances (e.g., band and loop, crown and loop, passive ●● Pre-existing occlusion. lingual arch, distal shoe, Nance appliance, transpalatal arch). ●● Favorable space analysis. ●● Removable appliances (e.g., partial dentures, Hawley appliance). ●● Presence and root development of permanent successor. The placement and retention of space-maintaining appliances requires ●● Amount of alveolar bone covering permanent successor. ongoing compliant patient behavior. Follow-up of patients with space ●● Patient’s health status. maintainers is necessary to assess integrity of cement and to evaluate ●● Patient’s cooperative ability. and clean the abutment teeth. The appliance should function until the ●● Active oral habits. succedaneous teeth have erupted into the arch. ●● Oral hygiene. The goal of space maintenance is to prevent loss of arch length, width If a space analysis is required before the placement of a space and perimeter by maintaining the relative position of the existing maintainer, appropriate radiographs and study models should be dentition. considered.

Regaining space Treatment modalities may include fixed appliances or removable The goal of space-regaining intervention is the recovery of lost arch appliances (e.g., Hawley appliance, lip bumper, headgear). Space width and perimeter and improved eruptive position of permanent, loss and dentofacial skeletal development may dictate that space succedaneous teeth. Space regained should be maintained until regaining not be indicated. This should be determined as the result of a adjacent permanent teeth have erupted completely or until a comprehensive analysis. The timing of clinical intervention subsequent subsequent comprehensive orthodontic treatment plan is initiated. to premature loss of a primary molar is critical.

Crossbites (dental, functional, and skeletal) Crossbites should be considered in the context of the patient’s total ++ Redirect skeletal growth. treatment needs. Anterior crossbite correction can: ++ Improve the tooth-to-alveolus relationship. ++ Reduce dental attrition. ++ Increase arch perimeter. ++ Improve dental aesthetic.

Page 132 Dental.EliteCME.com A simple anterior crossbite can be aligned as soon as the condition ●● A combination of these treatment modalities to correct the palatal is noted if there is sufficient space; otherwise, space will need to be constriction. created with the use of fixed appliances, acrylic incline planes, acrylic Fixed or removable palatal expanders can be utilized until midline retainers or expansion appliances, depending how much space is suture fusion occurs. Treatment decisions depend on the: required. ●● Amount and type of movement (tipping versus bodily movement, Posterior crossbite correction can accomplish the same objectives and rotation, or dental versus orthopedic movement). can improve the eruptive position of the succedaneous teeth. Early ●● Space available. correction of unilateral posterior crossbites has been shown to improve ●● AP, transverse and vertical skeletal relationships. functional conditions significantly and largely eliminate morphological ●● Growth status. and positional asymmetries of the mandible. Functional shifts should ●● Patient cooperation. be eliminated as soon as possible with early correction to avoid Patients with crossbites and concomitant Class III skeletal patterns asymmetric growth. Treatment can be completed with: or skeletal asymmetry should receive comprehensive treatment as ●● Equilibration. covered in the Class III malocclusion section. ●● Appliance therapy (fixed or removable). ●● Extractions. Treatment of a crossbite should result in improved intramaxillary alignment and an acceptable interarch occlusion and function.

Class II malocclusion Factors to consider when planning orthodontic intervention for Class Treatment modalities include: (1) extraoral appliances (headgear), (2) II malocclusion are: (1) facial growth pattern, (2) amount of AP functional appliances, (3) fixed appliances, (4) tooth extraction and discrepancy, (3) patient age, (4) projected patient compliance, (5) interarch elastics, and (5) orthodontics with orthognathic surgery. space analysis, (6) anchorage requirements, and (7) patient and parent Treatment of a developing Class II malocclusion should result in an desires. improved overbite, overjet, and intercuspation of posterior teeth and an aesthetic appearance and profile compatible with the patient’s skeletal morphology.

Class III malocclusion Treatment of class III malocclusions is indicated to provide Treatment of a developing class III malocclusion should result in psychosocial benefits for the child patient by reducing or eliminating improved overbite, overjet, and intercuspation of posterior teeth and an facial disfigurement and to reduce the severity of malocclusion by aesthetic appearance and profile compatible with the patient’s skeletal promoting harmonious growth. Early Class III treatment has been morphology. proposed for several years and has been advocated as a necessary tool Potential benefits in contemporary orthodontics. ++ Guidance of eruption and development of the primary, mixed and Factors to consider when planning orthodontic intervention for Class permanent dentitions is an integral component of comprehensive III malocclusion are: (1) facial growth pattern, (2) amount of AP oral health care for all pediatric dental patients. Such guidance discrepancy, (3) patient age, (4) projected patient compliance, (5) should contribute to the development of a permanent dentition space analysis, (6) anchorage (headgear), (7) functional appliances, (8) that is in a stable, functional and aesthetically acceptable fixed appliances, (9) tooth extraction, (10) interarch elastics, and (11) occlusion. Early diagnosis and successful treatment of developing orthodontics with orthognathic surgery. malocclusions can have both short-term and long-term benefits Early class III treatment may provide a more favorable environment while achieving the goals of occlusal harmony and function and for growth and to improve occlusion, function and aesthetics. dentofacial aesthetics. Although early treatment can minimize the malocclusion and Potential risks potentially eliminate future orthognathic surgery, this is not always Adverse effects associated with space maintainers include: possible. Typically, class III patients tend to grow longer and more XX Dislodged, broken and lost appliances. unpredictably and, therefore, surgery combined with orthodontics is XX Plaque accumulation. the best alternative to achieve a satisfactory result for some patients. XX Caries. XX Interference with successor eruption. XX Undesirable tooth.

Oral surgery and the child patient This section provides updated information regarding best practices for ●● Supernumerary teeth and mesiodens. oral surgery and addressing the following topics: ●● Oral lesions in the newborn such as Epstein’s pearls, dental lamina Diseases and disorders: cysts, Bohn’s nodules, and congenital epulis (Neumann’s tumor). ●● Odontogenic infections. ●● Eruption cysts. ●● Erupted teeth needing extraction. ●● Mucocele. ●● Fractured teeth. ●● Oral structural anomalies such as maxillary frenum, mandibular ●● Unerupted and impacted teeth. labial frenum, mandibular lingual frenum/ankyloglossia, and natal and neonatal teeth.

Assessment 1. Physical exam. 3. Radiographic evaluation. 2. Differential diagnosis.

Dental.EliteCME.com Page 133 Treatment 1. Treatment of odontogenic infections and associated complications: 5. Evaluation and management of oral pathologies occurring in the ○○ Pulp therapy. newborn. ○○ Extraction or incision and drainage. 6. Surgical opening of eruption cyst. ○○ Antibiotic therapy. 7. Surgical excision of mucocele and adjacent minor salivary glands. ○○ Hospitalization and referral/consultation with an oral and 8. Frenectomy (for maxillary frenum and mandibular labial and maxillofacial surgeon. lingual frenum) and frenectomy techniques. 2. Extraction of erupted and unerupted teeth. 9. Frenuloplasty and frenectomy (for ankyloglossia). 3. Management of fractured primary tooth roots. 10. Assessment and treatment of Riga-Fede disease. 4. Management of unerupted, impacted, and supernumerary teeth.

Odontogenic infections In children, odontogenic infections may involve more than one tooth teeth, skin, local lymph nodes and salivary glands. Swelling of the and usually are due to carious lesions, periodontal problems, or a lower face more commonly has been associated with dental infection. history of trauma. Untreated odontogenic infections can lead to pain, Most odontogenic infections can be managed with pulp therapy, abscess and cellulitis. As a consequence of this, children are prone to extraction, or incision and drainage. Infections of odontogenic dehydration – especially if they are not eating well because of pain and origin with systemic manifestations (e.g., elevated temperature of malaise. Prompt treatment of the source of infection is important to 102 degrees to 104 degrees F, facial cellulitis, difficulty in breathing control pain and prevent the spread of infection. or swallowing, fatigue, nausea) require antibiotic therapy. Severe With infections of the upper portion of the face, patients usually but rare complications of odontogenic infections include cavernous complain of facial pain, fever and inability to eat or drink. Care must sinus thrombosis and Ludwig’s angina. These conditions can be be taken to rule out sinusitis, because its symptoms may mimic an life threatening and may require immediate hospitalization with odontogenic infection. Occasionally in upper face infections, it may intravenous antibiotics, incision and drainage, and referral/consultation be difficult to find the true cause. Infections of the lower face usually with an oral and maxillofacial surgeon. involve pain, swelling and trismus. They frequently are associated with

Extraction of erupted maxillary and mandibular anterior teeth Most primary and permanent maxillary and mandibular central Radiographic examination is helpful to identify differences in root incisors, lateral incisors, and canines have conical single roots. In most anatomy prior to extraction. Care should be taken to avoid placing any cases, extraction of anterior teeth is accomplished with a rotational force on adjacent teeth that could become luxated or dislodged easily movement because of their single root anatomies. However, there have due to their root anatomy. been reported cases of accessory roots observed in primary canines.

Extraction of erupted maxillary and mandibular molars Primary molars have roots that are smaller in diameter and more completed. Primary molars with roots encircling the successor’s crown divergent than permanent molars. Root fracture in primary molars is may need to be sectioned to protect the permanent tooth’s location. not uncommon because of these characteristics as well as the potential Molar extractions are accomplished by using slow continuous palatal/ weakening of the roots caused by the eruption of their permanent lingual and buccal force allowing for the expansion of the alveolar successors. To avoid inadvertent extraction or dislocation of or trauma bone to accommodate the divergent roots and reduce the risk of root to the permanent successor, careful evaluation of the relationship of fracture. When extracting mandibular molars, care should be taken to the primary roots to the developing succedaneous tooth should be support the mandible to protect the temporomandibular joints from injury.

Fractured primary tooth roots The dilemma to consider when treating a fractured primary tooth root that if the fractured root tip can be removed easily, it should be is that removing the root tip may cause damage to the succedaneous removed. If the root tip is very small, located deep in the socket tooth, while leaving the root tip may increase the chance for situated in close proximity to the permanent successor or unable to be postoperative infection and delay eruption of the permanent successor. retrieved after several attempts, it is best left to be resorbed. Radiographs can assist in the decision process. The literature suggests

Impacted canines Permanent maxillary canines are second to third molars in frequency Extraction of the primary canines is the treatment of choice when of impaction. Early detection of an ectopically erupting canine through malformation or ankylosis is present, when the risk of resorption of the visual inspection, palpation and radiographic examination is important adjacent tooth is evident, or when trying to correct palatally impacted to minimize such an occurrence. Panoramic and periapical films are canines, provided there are normal space conditions and no incisor useful in locating potentially ectopic canines. Routine evaluation of resorption. One study showed that 78 percent of ectopically erupting patients in mid-mixed dentition should involve identifying signs, permanent canines normalized within 12 months after removal of such as lack of canine bulges and asymmetry in pattern of exfoliation. the primary canines; 64 percent normalized when the starting canine Eruption of canines and abnormal angulation or ectopic eruption of position overlapped the lateral incisor by more than half of the developing permanent cuspids can be detected with a radiograph. root and 91 percent normalized when the starting canine position When the cusp tip of the permanent canine is just mesial to or overlapped the lateral incisor by less than half of the root. overlaying the distal half of the long axis of the root of the permanent lateral incisor, canine palatal impaction usually occurs.

Page 134 Dental.EliteCME.com If no improvement in canine position occurs in a year, surgical or permanent maxillary canines, the literature suggests that this can orthodontic treatment was suggested. Although a Cochrane review be considered to minimize complications resulting from impacted yielded a lack of randomized controlled clinical studies to support canines. Consultation between the practitioner and an orthodontist may extraction of primary canines to facilitate eruption of ectopic be useful in the final treatment decision.

Third molars Panoramic or periapical radiographic examination is indicated in third molar removal in adults is safe with minimal complications and late adolescence to assess the presence, position and development of negative effects on the patient’s quality of life. The report showed that third molars. The American Association of Oral and Maxillofacial mandibular third molars exhibited more pathology or abnormalities. Surgeons (AAOMS) recommends that a decision to remove or retain All intraoperative complications (e.g., nerve injury, unexpected third molars should be made before the middle of the third decade. hemorrhage, unplanned transfusion or parenteral drugs, compromised Little controversy surrounds their removal when pathology (e.g., airway, fracture, other injuries to adjacent teeth/structures) occurred cysts or tumors, caries, infection, pericoronitis, periodontal disease, at a frequency of less than 1 percent. Excluding alveolar osteitis, detrimental changes of adjacent teeth or bone) is associated or the postoperative complications (e.g., paresthesia, infection, trismus, tooth is malpositioned or nonfunctional (i.e., an unopposed tooth). A hemorrhage) were similarly low. Factors that increase the risk systematic review of research literature from 1984 to 1999 concluded for complications (e.g., coexisting systemic conditions, location there is no reliable evidence to support the prophylactic removal of of peripheral nerves, history of temporomandibular joint disease, disease-free impacted third molars. Although prophylactic removal of presence of cysts or tumors) and position and inclination of the all impacted or unerupted disease-free third molars is not indicated, molar in question should be assessed. The age of the patient is only a consideration should be given to removal by the third decade when secondary consideration. Referral to an oral and maxillofacial surgeon there is a high probability of disease or pathology or the risks for consultation and subsequent treatment may be indicated. associated with early removal are less than the risks of later removal. When a decision is made to retain impacted third molars, they should Removing the third molars before complete root formation may be be monitored for change in position and development of pathology, surgically prudent. which may necessitate later removal. AAOMS performed an age-related third molar study among board- certified oral and maxillofacial surgeons in 2001 and concluded that

Supernumerary teeth Supernumerary teeth and hyperdontia are terms to describe an excess Complications of supernumerary teeth can include delayed or lack in tooth number. Supernumerary teeth are thought to be related of eruption of the permanent tooth, crowding, resorption of adjacent to disturbances in the initiation and proliferation stages of dental teeth, dentigerous cyst formation, pericoronal space ossification, and development. Although some supernumerary teeth may be syndrome crown resorption. Early diagnosis and appropriately timed treatment associated (e.g., cleidocranial dysplasia) or of familial inheritance are important in the prevention and avoidance of these complications. pattern, most supernumerary teeth occur as isolated events. Because only 25 percent of all mesiodens erupt spontaneously, surgical Supernumerary teeth can occur in either the primary or permanent management often is necessary. A mesiodens that is conical in shape dentition. In 33 percent of the cases, a supernumerary tooth in the and is not inverted has a better chance for eruption than a mesiodens primary dentition is followed by the supernumerary tooth complement that is tubercular in shape and is inverted. The treatment objective for in the permanent dentition. Reports in incidence of supernumerary a nonerupting permanent mesiodens is to minimize eruption problems teeth can be as high as 3 percent, with the permanent dentition being for the permanent incisors. Surgical management will vary depending affected five times more frequently than the primary dentition and on the size, shape and number of supernumeraries and the patient’s males being affected twice as frequently as females. dental development. The treatment objective for a nonerupting Supernumerary teeth will occur 10 times more often in the maxillary primary mesiodens differs in that the removal of these teeth usually arch versus the mandibular arch. Approximately 90 percent of all is not recommended, because the surgical intervention may disrupt or single tooth supernumerary teeth are found in the maxillary arch, with damage the underlying developing permanent teeth. Erupted primary a strong predilection to the anterior region. The maxillary anterior tooth mesiodens typically are left to shed normally upon the eruption midline is the most common site, in which case the supernumerary of the permanent dentition. tooth is known as a mesiodens; the second most common site is Extraction of an unerupted primary or permanent mesiodens is the maxillary molar area, with the tooth known as a paramolar. A recommended during the mixed dentition to allow the normal mesiodens can be suspected if there is an asymmetric eruption pattern eruptive force of the permanent incisor to bring itself into the oral of the maxillary incisors, delayed eruption of the maxillary incisors cavity. Waiting until the adjacent incisors have at least two-thirds with or without any over-retained primary incisors, or ectopic eruption root development will present less risk to the developing teeth but of a maxillary incisor. The diagnosis of a mesiodens can be confirmed still allow spontaneous eruption of the incisors. In 75 percent of the with radiographs, including occlusal, periapical or panoramic films, cases, extraction of the mesiodens during the mixed dentition results or computed tomography. Three-dimensional information needed in spontaneous eruption and alignment of the adjacent teeth. If the to determine the location of the mesiodens or impacted tooth can adjacent teeth do not erupt within six to 12 months, surgical exposure be obtained by taking two periapical radiographs using either two and orthodontic treatment may be necessary to aid their eruption. The projections taken at right angles to one another or the tube shift diagnosing dentist may consider a multidisciplinary approach when technique (buccal object rule or Clark’s rule) or by cone beam treating difficult or complex cases. computed tomography.

Lesions of the newborn Oral pathologies occurring in newborn children include Epstein’s percent of newborns. They occur in the median palatal raphe area, as pearls, dental lamina cysts, Bohn’s nodules, and congenital epulis. a result of trapped epithelial remnants along the line of fusion of the Epstein’s pearls are common and found in about 75 percent to 80 palatal halves. Dental lamina cysts, found on the crests of the dental

Dental.EliteCME.com Page 135 ridges, most commonly are seen bilaterally in the region of the first Congenital epulis of the newborn, also known as granular cell tumor primary molars. They result from remnants of the dental lamina. or Neumann’s tumor, is a rare benign tumor seen only in newborns. Bohn’s nodules are remnants of salivary gland epithelium and usually This lesion is typically a protuberant mass arising from the gingival are found on the buccal and lingual aspects of the ridge, away from mucosa. It is most often found on the anterior maxillary ridge. Patients the midline. Epstein’s pearls, Bohn’s nodules, and dental lamina cysts typically present with feeding or respiratory problems. Congenital typically present as asymptomatic 1 mm to 3 mm nodules or papules. epulis has a marked predilection for females at 8:1 to 10:1. Treatment They are smooth, whitish in appearance, and filled with keratin. No normally consists of surgical excision. The newborn usually heals treatment is required; these cysts usually disappear during the first 3 well, and no future complications or treatment should be expected. months of life.

Eruption cyst (eruption hematoma) The eruption cyst is a soft tissue cyst that results from a separation trauma. If trauma is intense, these blood filled lesions sometimes are of the dental follicle from the crown of an erupting tooth. Fluid referred to as eruption hematomas. accumulation occurs within this created follicular space. Eruption cysts Because the tooth erupts through the lesion, no treatment is necessary. most commonly are found in the mandibular molar region. Color of If the cyst does not rupture spontaneously or the lesion becomes these lesions can range from normal to blue-black or brown, depending infected, the roof of the cyst may be opened surgically. on the amount of blood in the cystic fluid. The blood is secondary to

Mucocele The mucocele is a common lesion in children and adolescents resulting rupture. Mucoceles most frequently are observed on the lower lip, from the rupture of a minor salivary gland excretory duct, with usually lateral to the midline. Mucoceles also can be found on the subsequent leakage of mucin into the surrounding connective tissues buccal mucosa, ventral surface of the tongue, retromolar region, and that later may be surrounded in a fibrous capsule. Most mucoceles are floor of the mouth (ranula). well-circumscribed bluish translucent fluctuant swellings (although Superficial mucoceles and some other mucoceles are short-lived deeper and long-standing lesions may range from normal in color to lesions that burst spontaneously, leaving shallow ulcers that heal having a whitish keratinized surface) that are firm to palpation. Local within a few days. Many lesions, however, require treatment to mechanical trauma to the minor salivary gland is often the cause of minimize the risk of recurrence.

Maxillary frenum A prominent maxillary frenum in children, although a common Treatment options can include orthodontics, restorative dentistry, finding, is often a concern, especially when associated with a diastema. surgery, or a combination of these. When a diastema is present, the A comparison of attached frena with and without diastemas found no objectives for treatment involve managing both the diastems or correlation between the height of the frenum attachment and diastema permanent teeth and its cause while maintaining stable results in presence and width. Treatment is suggested when the attachment the future. It is recommended that treatment be delayed until the exerts a traumatic force on the gingival, causing the papilla to blanch permanent incisors and cuspids have erupted and the diastema has had when the upper lip is pulled, or if it causes a diastema to remain after an opportunity to close naturally. If orthodontic treatment is indicated, eruption of the permanent canines. Interference with oral hygiene the frenectomy (complete excision [i.e., removal of the whole measures, aesthetics and psychological reasons are contributing factors frenulum]) should be performed only after the diastema is closed as that relate to treatment of the maxillary frenum. much as possible to achieve stable results. When indicated, a maxillary frenectomy is a fairly simple procedure and can be performed in the office setting.

Mandibular labial frenum A high frenum can sometimes present on the labial aspect of the tissue, which, in turn, can lead to food and plaque accumulation. Early mandibular ridge. This is most often seen in the central incisor area treatment can be considered to prevent subsequent inflammation, and frequently occurs in individuals where the vestibule is shallow. recession, pocket formation, and possible loss of the alveolar bone or The mandibular anterior frenum, as it is known, occasionally inserts tooth. However, if factors causing gingival/periodontal inflammation into the free or marginal gingival tissue. Movements of the lower lip are controlled, the degree of recession and need for treatment cause the frenum to pull on the fibers inserting into the free marginal decreases.

Mandibular lingual frenum/ankyloglossia When indicated, frenuloplasty (various methods to release the tongue and speech. Further evidence is needed to determine the benefit of tie and correct the anatomic situation) or frenectomy (simple cutting of surgical correction of ankyloglossia in resolving speech pathology. the frenulum) may be a successful approach to facilitate breastfeeding; There is limited evidence to show an association between however, there is a need for evidence-based research to determine ankyloglossia and Class III malocclusion. Speculations have indications for treatment. This indicates that there is a need to been made that the abnormal tongue position may affect skeletal standardize a classification system and justify parameters for surgical development. Although there are no clear recommendations in the correction of ankyloglossia among neonates. literature, a complete orthodontic evaluation, diagnosis, and treatment Limitations in tongue mobility and speech pathology have been plan are necessary before any surgical intervention. associated with ankyloglossia. There has been varied opinion among Reports also have been made on the association between frenal health care professionals on the correlation between ankyloglossia and attachment and gingival recession; further clinical evidence, however, speech disorders. Frenuloplasty or frenectomy in conjunction with is warranted to show a clear relationship between these two factors. speech therapy can be a treatment option to improve tongue mobility

Page 136 Dental.EliteCME.com Elimination of plaque-induced gingival inflammation can minimize certain indications for these procedures. A short lingual frenum can gingival recession without any surgical intervention. inhibit tongue movement and create deglutition problems. If there is The significance and management of ankyloglossia are very no improvement in breastfeeding for a child with ankyloglossia after controversial because of the lack of evidence-based studies to non-surgical intervention, frenectomy may be indicated. support frenotomy, frenectomy and frenuloplasty among children and Although there is limited evidence in the literature to promote the adults affected by ankyloglossia. Studies have shown a difference in timing, indication and type of surgical intervention, frenectomy treatment recommendations among speech pathologists, pediatricians, for functional limitations due to severe ankyloglossia should be otolaryngologists, lactation specialists, surgeons, and dental considered on an individual basis. If evaluation shows that function specialists. Most professionals, however, will agree that there are may be improved by surgery, treatment should be considered.

Frenectomy techniques Frenectomy involves surgical incision, establishing hemostasis, and operative working time, the ability to control bleeding quickly, suturing of the wound. Dressing placement or the use of antibiotics reduced pain and discomfort, fewer postoperative complications (e.g., is not necessary. Recommendations include maintaining a soft diet, pain, swelling, infection), and no need for suture removal, as well regular oral hygiene, and analgesics as needed. Although there is as increasing patient acceptance. These procedures require skilled minimal evidence-based research available, the use of laser technology technique and patient management. and electrosurgery for frenectomies have demonstrated a shorter

Natal and neonatal teeth Natal and neonatal teeth can present a challenge when deciding on An important consideration when deciding to extract a natal appropriate treatment. Natal teeth have been defined as those teeth or neonatal tooth is the potential for hemorrhage. Extraction is present at birth, and neonatal teeth are those that erupt during the first contraindicated in newborns due to risk of hemorrhage. Unless 30 days of life. The occurrence of natal and neonatal teeth is rare; the child is at least 10 days old, consultation with the pediatrician the incidence varies from 1:1,000 to 1:30,000. The teeth most often regarding adequate hemostasis may be indicated prior to extraction of affected are the mandibular primary incisors. In most cases, anterior the tooth. natal and neonatal teeth are part of the normal complement of the Potential benefits dentition. Natal or neonatal molars have been identified in the posterior ++ Appropriate management and early treatment of infant, child and region and may be associated with systemic conditions or syndromes adolescent oral health problems and prevention of oral disease. (e.g., Pfieffer syndrome, histiocytosis X). Although many theories exist as to why the teeth erupt prematurely, currently no studies confirm a Potential risks causal relationship with any of the proposed theories. The superficial * Intraoperative complications of third molar removal (e.g., position of the tooth germ associated with a hereditary factor seems to nerve injury, unexpected hemorrhage, unplanned transfusion or be the most accepted possibility. parenteral drugs, compromised airway, fracture, other injuries to adjacent teeth/structures) occurred at a frequency less than 1 If the tooth is not excessively mobile or causing feeding problems, percent. Excluding alveolar osteitis, postoperative complications it should be preserved and maintained in a healthy condition if at all (e.g., paresthesia, infection, trismus, hemorrhage) were similarly possible. Close monitoring is indicated to ensure that the tooth remains low. stable. * Factors that increase the risk for complications (e.g., coexisting Riga-Fede disease is a condition caused by the natal or neonatal tooth systemic conditions, location of peripheral nerves, history of rubbing the ventral surface of the tongue during feeding leading temporomandibular joint disease, presence of cysts or tumors) to ulceration. Failure to diagnose and properly treat this lesion can and position and inclination of the molar in question should be result in dehydration and inadequate nutrient intake for the infant. assessed. Treatment should be conservative and focus on creating round, smooth Contraindications incisal edges. If conservative treatment does not correct the condition, XX Tooth extraction is contraindicated in newborns due to risk of extraction is the treatment of choice. hemorrhage.

Antibiotic therapy and the child patient This section discusses pediatric dental diseases requiring antibiotic 3. Duration of drug therapy. therapy, including oral wounds, dental trauma, orofacial infections 4. Patient education regarding the importance of completing a full and periodontal disease, with the objective of providing guidance in course of antibiotics. the appropriate use of antibiotic therapy in the treatment of these oral 5. Pulpotomy, pulpectomy or tooth extraction (for pulpitis). conditions. It considers the following interventions and practices: 6. Assessment of anesthesia requirements. 1. Antibiotic therapy: 7. Additional birth control measures for patients taking antibiotics ○○ Intravenous. and oral contraceptives. ○○ Intramuscular. Conservative use of antibiotics is indicated to minimize the risk of ○○ Oral. developing resistance to current antibiotic regimens. The following 2. Monitoring of clinical effectiveness of antibiotic therapy: general principles should be adhered to when prescribing antibiotics ○○ Culture and susceptibility testing of isolates from the infective for the pediatric population. site.

Oral wound management Factors related to host risk (e.g., age, systemic illness, malnutrition) Wounds can be classified as clean, potentially contaminated, and type of wound (e.g., laceration, puncture) must be evaluated when or contaminated/dirty. Topical or other antibiotic agents may be determining the risk for infection and subsequent need for antibiotics. required for facial lacerations and intraoral lacerations that appear

Dental.EliteCME.com Page 137 contaminated by extrinsic bacteria, as well as open fractures and joint responsive to the initial drug selection, a culture and susceptibility injury, which are susceptible to increased risk of infection. testing of isolates from the infective site may be indicated. If it is determined that antibiotics would be beneficial to the healing The minimal duration of drug therapy should be limited to five process, the timing of the administration of antibiotics is critical days beyond the point of substantial improvement or resolution of to supplement the natural host resistance in bacterial killing. The signs and symptoms; this is usually a five- to seven-day course of drug should be administered as soon as possible for the best result. treatment dependent upon the specific drug selected. The importance The most effective route of drug administration (intravenous versus of completing a full course of antibiotic must be emphasized. If the intramuscular versus oral) also must be considered. The clinical patient discontinues the antibiotic prematurely, the surviving bacteria effectiveness of the drug must be monitored. If the infection is not can restart an infection that may be resistant to the original antibiotic.

Pulpitis/apical periodontitis/draining sinus tract/localized intraoral swelling Bacteria can gain access to the pulpal tissue through caries, exposed rendered. Antibiotic therapy usually is not indicated if the dental pulp or dentinal tubules, cracks into the dentin, and defective infection is contained within the pulpal tissue or the immediately restorations. If a child presents with acute symptoms of pulpitis, surrounding tissue. In this case, the child will have no systemic signs treatment (i.e., pulpotomy, pulpectomy, or extraction) should be of an infection (i.e., no fever and no facial swelling).

Acute facial swelling of dental origin A child presenting with a facial swelling secondary to a dental treating the involved tooth/teeth. The clinician should consider the infection should receive immediate dental attention. Depending on ability to obtain adequate anesthesia, the severity of the infection, and clinical findings, treatment may consist of treating or extracting the medical status of the child. Intravenous antibiotic therapy and/or the tooth/teeth in question with antibiotic coverage or prescribing referral for medical management may be indicated. antibiotics for several days to contain the spread of infection and then

Dental trauma Local application of an antibiotic to the root surface of an avulsed consideration must be exercised in the systemic use of tetracycline tooth with an open apex and less than 60 minutes extraoral dry time due to the risk of discoloration in the developing permanent dentition. has been recommended, if available, to inhibit external reabsorption Penicillin V can be given as an alternative. The use of topical and aid in pulpal revascularization. Systemic antibiotics have been antibiotics to induce pulpal revascularization in immature non-vital recommended as an adjunctive therapy for avulsed permanent incisors traumatized teeth has been suggested. However, further randomized with an open or closed apex. Tetracycline is the drug of choice, but clinical trials are needed.

Pediatric periodontal diseases In pediatric periodontal diseases (e.g., neutropenias, Papillon-LeFevre some cases, treatment may involve antibiotic therapy. Culture and Syndrome, leukocyte adhesion deficiency), the immune system susceptibility testing of isolates from the involved sites is helpful in is unable to control the growth of periodontal pathogens, and, in guiding the drug selection.

Viral diseases Conditions such as acute primary herpetic gingivostomatitis should not be treated with antibiotic therapy unless there is strong evidence to indicate that a secondary bacterial infection exists.

Oral contraceptive use Whenever an antibiotic is prescribed to a female patient taking oral Potential risks contraceptives to prevent pregnancy, the patient must be advised to * Caution is advised with the concomitant use of antibiotics and oral use additional techniques of birth control during antibiotic therapy and contraceptives as antibiotics may decrease the effectiveness of oral for at least one week beyond the last dose because the antibiotic may contraceptives. render the oral contraceptive ineffective. * Tetracycline can cause discoloration in the developing permanent Rifampicin, tetracycline and penicillin derivatives have been shown dentition. to decrease the effectiveness of oral contraceptives, in some cases, by causing a significant decrease in the plasma concentrations of ethinyl estradiol, causing ovulation in some individuals taking oral contraceptives. Caution is advised with the concomitant use of antibiotics and oral contraceptives. Potential benefits ++ Conservative use of antibiotics may minimize the development of antibiotic resistance.

Bibliography ŠŠ American Academy of Pediatric Dentistry Clinical Affairs Committee-Restorative, Clinical guideline on pediatric restorative dentistry. Chicago (IL): American Academy American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline of Pediatric Dentistry; 2004. 9 p. on pediatric restorative dentistry. Pediatr Dent 2008-2009;30(7 Suppl):163-9. This ŠŠ Beauchamp J, Caufield PW, Crall JJ, Donly K, Feigal R, Gooch B, Ismail A, Kohn W, guideline updates a previous version: American Academy of Pediatric Dentistry. Siegal M, Simonsen R, American Dental Association Council on Scientific Affairs.

Page 138 Dental.EliteCME.com Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a is based in part on the American Academy of Pediatric Dentistry’s (AAPD’s) Policy report of the American Dental Association Council on Scientific Affairs. J Am Dent Statement on the Use of a Caries-risk Assessment Tool (CAT) for Infants, Children, Assoc 2008 Mar;139(3):257-68. and Adolescents and the American Academy of Periodontics’ (AAP) “Periodontal ŠŠ Council on Clinical Affairs. Guideline on xylitol use in caries prevention. Chicago Diseases in Children and Adolescents.” This guideline updates a previously published (IL): American Academy of Pediatric Dentistry (AAPD); 2011. 4 p. version: American Academy of Pediatric Dentistry. Clinical guideline on the role ŠŠ Guideline on behavior guidance for the pediatric dental patient. Chicago (IL): of dental prophylaxis in pediatric dentistry. Chicago (IL): American Academy of American Academy of Pediatric Dentistry (AAPD); 2011. 13 p. This guideline Pediatric Dentistry; 2003. 3 p. updates a previous version: American Academy of Pediatric Dentistry Clinical Affairs ŠŠ Guideline on use of anesthesia personnel in the administration of office-based deep Committee-Behavior, American Academy of Pediatric Dentistry Council on Clinical sedation/general anesthesia to the pediatric dental patient. Chicago (IL): American Affairs. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent Academy of Pediatric Dentistry (AAPD); 2009. 3 p. This summary updates a previous 2008-2009;30(7 Suppl):125-33. version: Clinical guideline on use of anesthesia-trained personnel in the provision ŠŠ Guideline on caries-risk assessment and management for infants, children and of general anesthesia/deep sedation to the pediatric dental patient. Chicago (IL): adolescents. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2011. American Academy of Pediatric Dentistry; 2001. 2 p. 8 p. This guideline updates a previous version: American Academy of Pediatric ŠŠ Guideline on use of antibiotic therapy for pediatric dental patients. Chicago (IL): Dentistry (AAPD). Policy on use of a caries-risk assessment tool (CAT) for infants, American Academy of Pediatric Dentistry (AAPD); 2009. 3 p. This guideline updates children and adolescents, revised 2006. a previous version: Clinical guideline on appropriate use of antibiotic therapy for ŠŠ Guideline on management of the developing dentition and occlusion in pediatric pediatric dental patients. Chicago (IL): American Academy of Pediatric Dentistry dentistry. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2009. 13 (AAPD); 2005. 3 p. p. This guideline updates a previous version: Clinical guideline on management of ŠŠ Guideline on use of local anesthesia for pediatric dental patients. Chicago (IL): the developing dentition and occlusion in pediatric dentistry. Chicago (IL): American American Academy of Pediatric Dentistry (AAPD); 2009. 7 p. This guideline updates Academy of Pediatric Dentistry (AAPD); 2005. 18 p. a previous version: Clinical guideline on appropriate use of local anesthesia for ŠŠ Guideline on pediatric oral surgery. Chicago (IL): American Academy of Pediatric pediatric dental patients. Chicago (IL): American Academy of Pediatric Dentistry Dentistry (AAPD); 2010. 8 p. This guideline updates a previous version: Guideline (AAPD); 2005. 8 p. on pediatric oral surgery. Chicago (IL): American Academy of Pediatric Dentistry ŠŠ Guideline on use of nitrous oxide for pediatric dental patients. Chicago (IL): American (AAPD); 2005. 9 p. Academy of Pediatric Dentistry (AAPD); 2009. 4 p. This guideline updates a previous ŠŠ Guideline on the role of dental prophylaxis in pediatric dentistry. Chicago (IL): version: Clinical guideline on appropriate use of nitrous oxide for pediatric dental American Academy of Pediatric Dentistry; 2007. 4 p. [18 references] The guideline patients. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2005. 4 p.

Topics in Pediatric Dentistry

Final Examination Questions Select the best answer for each question and mark your answers on the online at Dental.EliteCME.com.

1. Studies suggest that dentists’ technical skills are often judged by 6. HOME is a useful way to “show” that a procedure is not to be their “bedside manner,” or how caring and sympathetic they are feared by showing another child having a good experience with the perceived to be. same procedure. a. True. a. True. b. False. b. False.

2. Which of the following stages of cognitive development discussed 7. Informed consent must be obtained and documented in the by Piaget is characterized by the ability to predict outcomes? patient’s record prior to use of protective stabilization. a. Sensorimotor. a. True. b. Preoperational thought. b. False. c. Concrete operations. d. Formal operations. 8. Before delivery of deep sedation/general anesthesia, oxygen saturation must be monitored and recorded at least every 10 3. Fear of strangers is pronounced in many infants at about 4 months minutes throughout the procedure. of age, with anxiety separation relatively uncommon for children a. True. until about 5 years of age, when it increases markedly. b. False. a. True. b. False. 9. Guidelines for local anesthesia use in children were last revised in 2002. 4. Which of the following is not an effective strategy for reducing a. True. patient anxiety? b. False. a. Attempting to make the appointment as short as possible. b. Providing an age-appropriate explanation before any 10. Practitioners should aspirate before every local anesthetic injection procedure. and inject slowly. c. Listening to the child, and addressing any concerns or worries. a. True. d. Ensuring that treatment is pain-free. b. False.

5. Which of the following activities is not appropriate for the tell- 11. Which of the following is not a contraindication for the use of show-do sequence? supplemental injections to obtain local anesthesia? a. Explaining the procedure in phrases appropriate to the a. Use of a local anesthetic without vasoconstrictor for patients developmental level of the patient. with an allergy to bisulfates. b. Demonstrating the visual, auditory, olfactory and tactile b. Use of epinephrine in hyperthyroid patients. aspects of the procedure for the patient. c. Use of levonordefrin and norepinephrine in patients receiving c. Completing the procedure without deviating from the tricyclic antidepressants. explanation and demonstration. d. Use of the periodontal ligament injection or intraosseous d. Communicating the clinical or preventive objectives of the methods in the presence of inflammation or infection at the treatment to the parents of the patient. injection site.

Dental.EliteCME.com Page 139 12. If a rubber cup/pumice prophylaxis is performed, a topical fluoride 17. Distal tipping should be used for mildly impacted first permanent application is recommended. molars, where little of the tooth is impacted under the primary a. True. second molar. b. False. a. True. b. False. 13. The American Academy of Pediatrics does not recommend chewing gum use in children less than 2 years of age because of 18. There have been reported cases of accessory roots observed in the risk of choking. primary canines. a. True. a. True. b. False. b. False.

14. Children at high risk exhibiting anterior tooth caries and/or molar 19. Seventy-five percent of mesiodens erupt spontaneously. caries may be treated with SSCs to protect the remaining at-risk a. True. tooth surfaces. b. False. a. True. b. False. 20. Which of the following is not a term referring to smooth, whitish cysts, filled with keratin, which require no treatment and usually 15. Which of the following is not a clinical recommendation from a disappear during the first three months of life? study published in 2008 on sealants? a. Bohn’s nodules. a. Routine mechanical preparation of enamel before acid etching b. Epstein’s pearls. is recommended. c. Dental lamina cysts. b. When possible, a four-handed technique should be used for d. Congenital epulis. placement of resin-based sealants. c. Resin-based sealants are the first choice of material for dental sealants. d. Use of available self-etching bonding agents is not recommended.

16. Palpation for unerupted teeth should be part of every examination during the early mixed dentition stage. a. True. b. False.

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