Topics in Pediatric Dentistry
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Chapter 6: Topics in Pediatric Dentistry 8 CE Hours By: Elite Staff Learning objectives Identify the primary ways pediatric dentistry differs from treating List potential risks and contraindications for local anesthesia. adults. Discuss recent findings regarding xylitol and caries risk reduction. List the goals of behavior guidance. List a recommended use for restorative procedures described in List and describe the main components and objectives of the dental this course. consultation. List the clinical examination steps for unfavorable developing List four nonpharmacological behavior guidance strategies and dentition and occlusion. explain what is involved in each method. List the primary objectives for occlusion for each stage of Discuss some of the pros and cons of having parents present dentition. during treatment. Discuss the protocol for supernumerary teeth from infancy to Explain why nitrous oxide is typically preferred over protective young adolescent. stabilization as an advanced behavior guidance strategy. Describe the characteristics, causes and management of List contraindications and potential adverse effects for nitrous odontogenic infections in children. oxide/oxygen inhalation. Discuss the risks associated with excessive antibiotic therapy. 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 Objectives. pediatric patients. This chapter provides updated guidelines for the + Indications/recommendations. following practices and procedures specifically related to the child X Contraindications. patient: * Risks/cautions. ● Basic behavior guidance strategies. 9 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 Establish communication. children. Alleviate fear and anxiety. ● The staff must be trained carefully to support the dentist’s Deliver quality dental care. efforts and welcome the patient and parent into a child-friendly Build a trusting relationship between dentist, child and parent. environment that will facilitate behavior guidance and a positive 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