Guideline on Management of the Developing Dentition and Occlusion in Pediatric Dentistry.

Resident’s Name: Jessica Wilson Program: Lutheran Medical Center - Providence Article title: Guideline on Management of the Developing Dentition and Occlusion in Pediatric Dentistry. Author(s): Clinical Affairs Committee. Journal: AAPD Reference Manual. Year. Volume (number). Page #’s: 2009. 32(6). 213-225. Major topic: Occlusion Overview of method of research: Clinical Guidelines. Purpose: To set forth objectives for management of the developing dentition and occlusion in pediatric dentistry. Methods: Guideline is based on a review of current literature as well as best clinical practice and expert opinion. Recommendations: Oral habits: Habits may apply forces on dentition and dentoalveolar structures and habits with sufficient frequency, duration, and intensity may be associated with increased OJ, decreased OB, posterior crossbite or long facial height. The pressure from the lips, tongue and cheeks have the most effect on tooth position because of the constant duration of the forces. Tongue thrusting or abnormal swallowing patterns may be associated with anterior open bite, flaring of lower incisors and speech abnormalities however if the resting tongue position is normal, “a tongue thrust swallow has no clinical significance.” Research shows that mouth breathing with impaired nasal respiration may contribute to the increase of facial height, anterior open bite, increased OJ and a narrow palate, but this is not the major cause of these conditions. Obstruction sleep apnea syndrome (OSAS) may also be associated with these factors and a history with this syndrome often includes snoring, observed apnea, restless sleep, daytime sleepiness, and bedwetting as well as enlarged tonsils and adenoid facies. Nonnutritive sucking habits are normal in infants and young children, but prolonged habits should be addressed with anticipatory guidance for parents to help their children stop by the age of 36 months or earlier. Bruxism may occur while awake or asleep and is multifactorial in etiology including both central factors (stress, parasomnias, traumatic brain injury, neurologic disabilities) and morphologic factors (muscle recruitment and malocclusion). Complications such as headache, muscle soreness, TMJ problems, dental attrition may occur, but generally bruxism is suggested to be self-limiting that does not lead to adult bruxism. Treatment modalities include: education, occlusal splints, psychological techniques and medications. Self-mutilating is extremely rare in the normal child, but has been associated with mental retardation; psychiatric disorders, developmental disabilities and some syndromes and treatment may include pharmacological management, behavior modification and physical restraint. Some lip-liking or lip-pulling habits are less severe, but more severe biting habits may be associated with neurodisability due to severe brain damage. Dental treatment modalities such as lip bumper, occlusal bite appliances, odontoplasty, protective padding and extractions are sometimes indicated. Patients and parents should be educated about possible consequences of a habit. It is possible for the parent to have a negative effect on the correction of the habit as their nagging or punishment may produce an increase in the behavior. A change in the home environment may be required before cessation of a habit can occur. Referrals may be made to orthodontists, psychologists, myofunctional therapists, otolaryngologists or other specialists. Disturbances in number: Congenitally missing teeth should be expected in cleft lip and palate patients as well as those with certain syndromes and a familial pattern of missing teeth. In treatment for missing maxillary lateral incisors or mandibular second premolars, a practitioner may choose to extract the primary tooth and close the space orthodontically or open the space for an implant or prosthesis. Influential factors include: patient age, canine shape and position, crowding, occlusion, bite depth and amount and quality of bone present. The goal should be to provide an esthetic occlusion that functions well. Supernumerary teeth are 5 times more common in the permanent dentition with 80-90% in the maxilla. A primary supernumerary tooth is followed by a permanent supernumerary tooth 1/3 of the time. Only 25% of all mesiodens erupt spontaneously. Mesiodens can prevent or cause ectopic incisor eruption as well as cause incisor root dilacerations, cyst formation and possible eruption into the nasal cavity. Supernumerary primary dentition usually erupt in normal arch position and exfoliate normally. Removal of a mesiodens or other permanent supernumerary incisors result in the eruption of the normal incisor 75% of the time in the early mixed dentition, prior to root apex completion. Inverted supernumeraries may become more difficult to remove as they move deeper into the jaw. Radiographic evaluation after supernumerary removal should be performed 6 months later and if eruption of incisor is not evident, surgical exposure and extrusion may be indicated. Localized disturbances in eruption: Ectopic eruption (EE) of permanent 1st molars occurs less that 1% of the time and self-corrects or “jumps” in 66% of those cases. The impacted type presents as partial eruption of the permanent first molar with the mesial below the distal of the second primary molar and requires treatment in order to prevent the premature loss of the primary second molar and space loss. Treatment may include an ortho elastic separator for mild cases and brass wire, fixed appliances with open coil springs, sling shot-type appliances Halterman appliance or surgical uprighting for more severe cases. EE of permanent canines may be present as well as incisors, especially after trauma with pulpal treatment to primary incisors, asymmetric eruption or if supernumerary teeth are diagnosed. Extraction of the primary canine is indicated when no canine buldge is evident and radiographic evaluation presents overlapping canine with the lateral incisor. Ankylosis is most prevalent in primary molars which usually exfoliate normally, but extraction is recommended with prolonged retention. Ankylosis is also common with traumatized permanent incisors and can be verified radiographically or with palpation or percussion. Arch length and crowding are of particular importance with crowding being especially common in the early mixed dentition. Functional contacts are diminished with rotated teeth and TMJ problems and occlusal discrepancies may occur. Treatment considerations: primary canine extraction to aid the straight eruption of incisors, orthodontic alignment of permanent teeth, expansion, holding arches until all permanent canines and bicuspids have erupted, extractions of permanent teeth and possible interproximal reduction. Space maintenance: Space maintenance may be required for early loss of primary incisors when an intense digit habit exists as this may reduce space for the subsequent incisor. Possible adverse effects of space maintainers include: dislodged or broken appliances, plaque accumulation, caries, interference of erupting dentition, undesirable tooth movement, inhibition of alveolar growth, soft tissue impingement and pain. Space regaining: The timing of intervention after early loss of a primary molar is critical. Both fixed and removable appliances may be used and the goal of space regaining is the recovery of lost arch width and perimeter and improved eruption position of permanent teeth. Crossbites: Anterior crossbite correction can reduce dental attrition, improve esthetics, redirect skeletal growth, improve tooth to alveolus relationship and increase arch perimeter. Functional shifts should be corrected as soon as possible to avoid asymmetric growth via equilibration, appliance therapy, extractions or a combination of the above. Class II malocclusion: Class II occlusion can effectively be corrected by single or 2-phase regimen. Some studies found corrected class II skeletal pattern, whereas other studies found no changes. Different growth-modification treatments such as headgear or functional appliances show different results, but no reliable predictors have been found. Although evidence does not support significantly better results with 2-phase treatment, some clinicians choose to provide early treatment to improve self-esteem and eliminate significant overjet. When treating a class II patient, one should consider: facial growth pattern, age, AP discrepancy, projected compliance, space analysis, anchorage (headgear), patient and parental desires, functional appliances, fixed appliances, tooth extraction, interarch elastics, and orthodontics with orthognathic surgery. Class III malocclusion: Etiology was found to be about 56% hereditary in one study. The other 44% due to environmental factors such as trauma, oral/digital habits, caries and early childhood OSAS. Early treatment is recommended for improved function and esthetics and may eliminate future need for orthognathic surgery, however, class III growers are less predictable and surgery may still be necessary. When treating a class III patient, one should consider: facial growth pattern, age, AP discrepancy, projected compliance, space analysis, anchorage (headgear), functional appliances, fixed appliances, tooth extraction, interarch elastics, and orthodontics with orthognathic surgery. Assessment of Article: LONG, but great review.

Guideline on Pulp therapy for Primary and Immature Permanent Teeth

Resident: Swan
Article Title: Guideline on Pulp Therapy for Primary and Immature Permanent Teeth
Journal: Pediatric Dentistry
Volume (Number): 32(6).
Main Purpose: To aid in the diagnosis of pulp health vs. pathosis and to give indications, objectives, and interventions for pulp therapy in primary and immature permanent teeth.
Key Points: Correct pulpal therapy depends on correct diagnosis as vital or nonvital based on subjective and objective tests. From these tests we conclude if the tooth has normal pulp (symptom free and normally responsive to testing), reversible pulpitis (pulp capable of healing), irreversible pulpitits (inflamed pulp incapable of healing), or necrotic pulp. In permanent teeth, electric pulp tests and thermal tests are helpful.
Signs/symptoms of irreversible pulpitis/necrosis (non-vital therapy needed): history of spontaneous, unprovoked toothache, a sinus tract, soft tissue inflammation not resulting from gingivitis or periodontitis, excessive mobility not associated with trauma or exfoliation, furcal/apical radiolucency, internal/external resorption.
S/S of reversible pulpitis (vital therapy indicated): Provoked pain, short duration, relieved with OTC meds, by brushing, or upon the removal of stimulus.
A couple general recommendations: 1. Always perform pulp therapy with rubber dam to minimize contamination 2. X-ray of primary tooth pulpectomy should be obtained immediately following procedure. 3. Monitor posterior pulpotomies with x-rays that clearly show the interradicular area. Good bitewings can suffice.
Tx for Primary teeth:
Protective liner: thinly applied liquid applied to pulpal surface of deep cavity preparation, covering exposed dentin tubules and acting as protective barrier. Can be Calcium Hydroxide, dentin bonding agent, glass ionomer cement. Indicated in tooth with normal pulp.
Indirect pulp tx: performed in teeth w/ deep carious lesions but with no signs or symptoms of pulp degeneration. Caries surrounding pulp is left to avoid exposure, then covered with bonding agent, RMGI, CaOH2, IRM, GI. If CaOH2 is used, seal with GI or IRM to avoid microleakage. Current literature shows inconclusive evidence as to whether or not the tooth needs to be re-entered. IDPC has higher success rate than pulpotomy in long term studies and allows for normal exfoliation. Use for pulps that are normal or show reversible pulpitis.
Direct Pulp Cap: Place MTA or CaOH2 in contact with exposed pulp tissue after pinpoint mechanical exposure during cavity prep or following trauma. Then restore with material that provides good seal. Direct pulp capping of carious exposures is not recommended.
Pulpotomy: Performed in primary tooth with extensive caries but no radicular pathology when caries removal results in exposure. Coronal pulp amputated and remaining vital radicular tissue is treated with formocresol, ferric sulfate, or MTA. Most effective restoration is SSC. Amalgam or composite can be used if there’s enough tooth left and the remaining life span is 2 yrs or less. Do not perform pulpotomy if tooth shows continued suppuration, necrosis or excessive hemorrhage that can’t be controlled with damp cotton pellet after several minutes. If internal root resorption after pulpotomy can be be self-limiting and stable. Remove tooth is resorption casues loss of supportive bone or clinical signs of infection.
Nonvital tx for primary teeth with irreversible pulpitis or necrosis:
Pulpectomy: Tx for pulp tissue that has above conditions. Canals are debrided and shaped with hand file or rotary files. Irrigate with Sodium hypochlorite. Dry canals and fill with resorbable zinc oxide/eugenol or iodoform/CaOH2 mix (Vitapex). Restore tooth to prevent microleakage.
Treatment for young permanent teeth:
Protective liner: Same as for primary teeth
IDPC: Same as for primary teeth
Partial pulpotomy for carious exposures: Inflamed pulp tissue beneath exposure is removed to depth of 1 to 3 mm to reach healthy pulp tissue. Make sure bleeding is controlled with pressure/hypochlorite before covering with MTA or CaOH2. Layer with RMGI, then restore to prevent microleakage. Indicated in young permanent tooth with carious exposure in which pulpal bleeding is controlled within several minutes. Tooth must be vital, with healthy pulp or reversible pulptitis.
PP for traumatic exposures (Cvek): Same as above. Indicated for vital, traumatically-exposed young permanent tooth, especially one with incompletely formed apex.
Apexogenesis: formation of the apex in vital, young, permanent teeth can be accomplished by using the appropriate vital therapy described above.
Nonvital pulp treatment:
Pulpectomy (conventional endo tx)
Apexification: method of inducing root end closure of incompletely formed nonvital perm tooth. Remove coronal and nonvital radicular pulp and place CaOH2 for 2-4 weeks to disinfect the canal space. Root end closure is accomplished with an apical barrier like MTA. When complete closure can’t be accomplished with MTA, an absorbable collagen wound dressing (CollaCote) can be placed to form a matrix for the MTA at the root end. Gutta percha used to fill remaining canal space.

Guideline on Management of Acute Dental Trauma

Resident: Cho Author(s): AAPD Journal: Reference Manual Year. Volume (number). Page #’s: 2010-2011. V32. 202-212. Major topic: Dental TraumaType of Article: AAPD Guidelines Main Purpose: To define, describe appearances, and set forth objectives for general management of acute traumatic injuries. Methods: Electronic search was conducted using the following parameters: “teeth”, “trauma”, “permanent teeth”, “primary teeth”. Key points: - Greatest incidence of trauma to primary teeth occurs at 2-3 years when motor co-ordination is developing. - Greatest incidence of trauma to permanent teeth occur secondary to falls, followed by traffic accidents, violence, and sports. - The AAPD encourages the use of protective gear, including mouthguards. - Dentists have ethical obligation to ensure emergency dental care is available. - History, circumstances of the injury, pattern of trauma, and behavior of the child and/or caregiver are important in distinguishing nonabusive injuries from abuse. - Compromised airway, neurological manifestations such as altered orientation, hemorrhage, nausea/vomiting, or suspected loss of consciousness requires further evaluation by a physician. - Assessment includes a thorough medical and dental history, clinical and radiographic examination, and additional tests such as palpation, percussion, sensitivity, and mobility evaluation. - The risk of trauma-induced developmental disturbances in the permanent successors is greater in children whose enamel calcification is incomplete. Recommendations: Infraction: incomplete fracture (crack) of the enamel without loss of tooth structure, complications are rare. Crown fracture (uncomplicated): fracture that does include the pulp, look for fragments of tooth in gingiva, lips, tongue, small fracture – smooth margins, larger fractures – restore tooth structure Crown fracture (complicated): fracture that includes pulp exposure, look for fragments of tooth in gingiva, lips, tongue, primary tooth – pulpotomy, pulpectomy, extraction, permanent tooth – direct pulp cap, partial pulpotomy, full pulpotomy, and pulpectomy. Crown/root fracture: enamel, dentin, and cementum fracture with or without pulp exposure, mobile coronal fragment attached to the gingiva, primary tooth – entire tooth should be removed unless retrieval of apical fragments may result in damage to succedaneous tooth, permanent tooth – remove coronal fragment, supragingival restoration or gingivectomy, osteotomy, or surgical or ortho extrusion to prepare for restoration, most fractured permanent teeth can be saved as long as fracture not too subgingival. Root fracture: Dentin and cementum fracture involving the pulp, mobile coronal fragment attached to the gingiva, multiple xrays taken at different angles may be necessary, primary tooth – extraction of coronal portion only, permanent tooth – reposition and stabilize coronal fragment. Concussion: injury to the tooth-supporting structures without abnormal loosening or displacement of the tooth, watch tooth. Subluxation: injury to the tooth-supporting structures with abnormal loosening but without tooth displacement, primary tooth – watch for pathology, permanent tooth – stabilize tooth and relieve any occlusal interferences, splint for no more than 2 weeks. Lateral luxation: displacement of the tooth in a direction other than axially, tooth is displaced laterally with the crown usually in a palatal or lingual direction, widened PDL, displacement of apex toward or through the labial bone plate, primary tooth - allow passive or spontaneous repositioning if no occlusal interference, gentle repositioning if occlusal interference, extraction if tooth is nearing exfoliation, permanent tooth – reposition ASAP, splint 2-4 weeks may be needed. Intrusion: apical displacement of tooth into alveolar bone, if tooth appears shorter in xray than contra-lateral then apex is displaced labially, if tooth appears longer in xray than contra-lateral then apex is displaced palatally toward permanent tooth bud, primary tooth: allow spontaneous reeruption unless displaced toward permanent tooth bud, immature permanent tooth (½ to ¾ root formed): wait for reeruption, mature permanent tooth: actively reposition tooth with ortho or surgical extrusion, stabilize with splint for up to 4 weeks, initiate endo within first 3 weeks. Extrusion: partial displacement of the tooth axially from the socket (partial avulsion), widened PDL apically on xray, primary tooth – allow tooth to spontaneously reposition or reposition and allow for healing for minor extrusion of <3mm in immature developing tooth, extract for fully formed tooth, severe extrusion or mobility, child uncooperative, permanent tooth – reposition ASAP, stabilize with splint for up to 2 weeks. Avulsion: complete displacement out of socket, primary tooth – do not replant, permanent tooth – replant ASAP and flexible splint for 2 weeks, tetanus prophylaxis, antibiotic coverage, exceptions for replantation: a) child’s stage of dental development where considerable alveolar growth has to take place, high risk of ankylosis b) compromising medical condition - immunocompromised health, severe congenital cardiac anomalies, severe uncontrolled seizure disorder, severe mental disability, severe uncontrolled diabetes c) compromised integrity of avulsed tooth or supporting tissues d) PDL has no chance of survival if in dry environment greater than 60 minutes Orthodontic movement of traumatized teeth: Concussion, subluxation, extrusion, simple crown/root fracture – wait 3 months before beginning ortho; moderate to severe trauma to periodontium – wait 6 months, root fracture – wait 1 year. Light intermittent forces are recommended along with avoidance of prolonged tipping forces and contact with buccal and lingual cortical plates. Assessment of Article: Great article. Lots of information – has assessment of acute traumatic injuries chart in the back, good overview of trauma.

Guideline on Antibiotic Prophylaxis (AP) for Dental Patients at Risk for Infection

Resident: J. Hencler
Date: 03/30/2011

Article title: Guideline on Antibiotic Prophylaxis (AP) for Dental Patients at Risk for Infection

Author(s): AAPD Council on Clinical Affairs
Journal: Reference Manual V32/NO6 10/11

Major topic: Antibiotic Prophylaxis

Type of Article: Guidelines/Reference

Main Purpose: Help practitioners make appropriate decisions regarding AP for at risk dental patients.

Key points in the article discussion:
Numerous med conditions predispose patients to bacteremia-induced infections. Bacteremia is anticipated following invasive dental tx. Prophylactic antibiotics are recommended for such at risk patients and should be determined on an individual basis. In 2007 the AHA revised and released new guidelines 1) IE is more likely to result from frequent bacterial exposure associated with daily activities then from dental tx, 2) prophylaxis may only prevent a very small number of IE cases if any of individuals that undergo dental tx, 3) the risk of antibiotic-associated adverse events exceeds benefit if any from prophylactic antibiotic therapy, and 4) maintenance of optimal oral health and hygiene may reduce incidence of bacteremia and is more important than prophylactic antibiotics to reduce risk b/f dental tx. Major changes from 1997 guidelines include: 1) the AHA concluded that only a small number of cases of IE might be prevented by AP for dental tx even if such AP were 100% effective, 2) IE AP for dental procedures is reasonable only for patients w/ cardiac conditions associated w/ the HIGHEST risk of IE, 3) AP is required for all dental procedures that involve manipulation of gingival, PA region, or perforation of mucosa, and 4) AP not recommended on increased lifetime risk of acquiring IE.

Recommendations: The conservative use of antibiotics is indicated to minimize the development of resistance to current antibiotic regimens.

Cardiac:
AHA recommends AP for conditions including prosthetic heart valves, hx of IE, unrepaired cyanotic CHD, repaired congenital heart defect w/ prosthetic material or device during the first 6 months, repaired CHD w/ residual defects at the site or adjacent to the site of a prosthetic patch or device, and cardiac transplantation recipients who develop valvulopathy. In addition, patients with a history of IV drug abuse may be at risk for developing bacterial endocarditis due to cardiac anomalies.

Immunocompromised:
These patients may not be able to tolerate a transient bacteria following dental tx and include conditions such as: HIV, severe combined immunodeficiency, neutropenia, immunosuppression, sickle cell anemia, status post splenectomy, chronic steroid usage, lupus, diabetes, and status post organ transplantation.

Shunts, indwelling vascular catheters, or medical devices:
AP for nonvalvular devices, including indwelling vascular catheters (central lines) is indicated only at time of placement. The AHA found no evidence that dental procedures cause infection of nonvalvular devices any time after implantation. Immunocompromised patients w/ nonvalvular devices should receive AP. Ventriculoatrial (VA) or ventriculovenus (VV) shunts for hydrocephalus are at risk for bacteremia-induced infections due to their vascular access require AP. Ventriculoperitoneal (VP) shunts don’t involve any vascular structure and do not require AP. AP is not indicated for patients w/ pins, plates, and screws, nor is it indicated routinely for most dental patients w/ total joint replacements. AP may be considered when high-risk dental procedures are performed for patients w/ in 2 yrs following implant surgery or for patients who have had previous joint infections. ALWAYS consult w/ PCP or specialist!

Assessment of article: Know it, Love it, Use it!

3/30/11 Guideline on Acquired Temporomandibular Disorders in Infants, Children, and Adolescents

Department of Pediatric Dentistry
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title: Guideline on Acquired Temporomandibular Disorders in Infants, Children, and Adolescents
Author(s): Review Council
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2010 v32 No 6 pg 232-278
Major topic: TMD
Minor topic(s):
Main Purpose: To assist in the recognition and diagnosis of TMD and to identify possible treatment options. This guideline is not aimed at recommending specific tx modalities.
Overview of method of research: Electronic search using buzz words for TMD. 69 articles were reviewed.

Findings:
In the development and growth of the TMJ, function influences form. The TMJ is made up of three major components, The mandibular condyle, fossa, and associated connective tissue (articular disk). The TMJ starts to develop 8 weeks after conception.
1st decade-Condyle becomes less vascularized, most morphologic changes are complete
2nd decade-Continued slow growth
3rd decade-Condyle changes form wider than longer
Lifetime-TMJ changes throughout life

TMD has been defined as “functional disturbances of the masticatory system”. Masticatory muscle issues, degenerative/inflammatory changes in the TMJ, and TMJ displacement can also be included in the definition. Certain medical conditions may mimic TMJ symptoms, including psychological disorders such as anxiety, mood disorders, etc.

TMD disorders have multiple etiological factors. An alteration any combination of teeth, PDL, TMJ, or MOM can lead to TMD. Other factors include
-Trauma
-Occlusal Forces such as open bite, overjet >6mm, retrocuspal position, ClassIII, or missing >5 posterior teeth
-Parafunctional habits
-Posture
-Changes in freeway dimension
Current literature does not support that development of TMD is caused by orthodontics.

TMD can present in infants, children, adolescents, and adults. Approx. 25% of children have TMJ, with clicking being the most common symptom. Recent reviews show that girls are more effected than boys (early puberty).

All comprehensive dental exams should include a TMJ exam. Various questions should be asked about the TMJ, including

-Difficulty opening?
-Hear noise when you open?
-Pain in/around ears? Cheeks? When chewing? Opening? Yawning?
-Has bite changed?
-Ever get locked open?
-Any head/neck injuries?

Clinical assessment should include palpation, auscultation, examination of jaw movements, and radiographs.

Simple, conservative, reversible tx is best for children. Tx should be aimed at finding a balance between active and passive tx options. Tx may include
Reversible
-Patient education ie relaxation training, coping strategies
-Physical therapy ie jaw exercises, transcutaneous electrical nerve stimulation
-Behavioral therapy
-Prescription meds is NSAIDS
-Occlusal splints

Irreversible
-Occlusal adjustment
-Mandibular repositioning surgery
-Orthodontics

If you’re not comfortable treating or diagnosing TMD, refer.
Key points/Summary:
Main points are that kids, infants even can have TMD. We need to be aware of it, and make sure we ask our patients about it regularly. Always be sure to assess the TMJ if trauma has occurred. Tx for kids should be reversible, and should go from less invasive to most.

Assessment of Article: Another lovely guideline. Good stuff.

Guideline on Prescribing Dental Radiographs for Infants, Children, Adolecents, and Persons with Special Health Care Needs.

Resident: Adam J. Bottrill
Date: 23MAR11
Region: Providence
Article title: Guideline on Prescribing Dental Radiographs for Infants, Children, Adolescents, and Persons with Special Health Care Needs.
Journal: Pediatric Dentistry Reference Manual
Page #s: 272-274
Vol:No Date: 2010
Major topic: Dental Radiographs
Minor topic(s): None
Type of Article: Guidelines

Main Purpose: This guideline is intended to help practitioners make clinical decisions concerning appropriate selection of dental radiographs as part of an oral evaluation of infants, children, adolescents, and persons with special health care needs.

Key points in the article discussion:

I. General:

A. The recommendations in past ADA/FDA guidelines were developed to serve as an ADJUNCT to the dentist's professional judgment.
B. Timing of initial radiographic exam should be based on individual circumstances.
C. Should be performed only when there is an expectation that the Dx yield will affect patient care.
D. If radiographs of diagnostic quality are unobtainable, practitioner should confer with parent to decide on proper management techniques (in office, increased recall frequency, OR etc...)
E. ALARA (Time, Distance, Shielding)
F. Cone Beam CT is being researched and investigated for potential use in dentistry

II. Recommendations:

























A. Recommendations are subject to clinical judgement and may not apply to every patient.
B. Protective aprons and thyroid collars should be used whenever possible.
1. Strongly recommended for children, pregnant women, and women of child-bearing age.
C. When using CBCT, should follow all guidelines of the AAOMR and provide written supplement to any imaging that is included in the patient chart.


Assessment of Article: Radiation and radiographs can be a touchy subject. It's good to have "policy" to back up our decisions regarding this aspect of patient care.

Guideline on Oral Health Care/Dental Management of heritable Dental Developmental Anomalies

Meghan Sullivan Walsh March 29, 2011

Literature Review - St. Joseph/LMC Pediatric Dentistry

Guideline on Oral Health Care/Dental Management of heritable Dental Developmental Anomalies

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Guideline on Oral Health Care/Dental Management of Heritable Dental developmental Anomalies

Authors: Council on Clinical Affairs

Journal: Pediatric Dentistry Reference Manual

Volume (number), Year, Page #’s; V32/NO 6 10/11, 226-231

Major Topic: Guidelines addressing the diagnosis, principles of management,and objectives of therapy of children with heritable dental developmental anomalies. Focus on Amelogenesis Imperfecta, Dentinogenesis Imperfecta and Dentin Dysplasia.

Overview of Method of Research: Electronic MEDLINE search of medical literature related to dental developmental anomalies.

Findings:

A disruption during histodifferentiation, apposition and mineralization can result in enamel hypoplasia, AI, DI and DD. These dental anomalies can have a profound affect in the individual regarding esthetics, self esteem, mastication, sensitivity, finances and dental treatment. These guidelines are focused on the diagnosis and management of three dental anomalies AI, DI and DD.

Amelogenesis Imperfecta:

-Developmental disturbance that effects normal enamel formation.

-Affects nearly all permanent and primary dentition.

-Estimated frequency of 1:7,000

-May be x-linked recessive, autosomal dominant or recessive or sporadic inheritance.

Clinical Manifestation:

-Accelerated or late tooth eruption

-Enlarged follicles

-Impacted permanent teeth

-Ectopic eruption

-Agenesis of second molars

-Anterior open bite

4 types:

Hypocalcified - normal thickness, smooth surface, less hardness

Hypoplastic pitted -normal thickness, pitted surface, normal hardness

Hypoplastic generalized - reduced thickness, smooth surface, normal hardness

Hypomaturation -normal thickness, chipped surface, less hardness, opaque white coloration.

Management:

Timely intervention is critical to prevent potential disfiguring conditions. Preventative care includes early diagnosis, regular periodic examinations, meticulous hygiene, oral rinses and application of fluoride or desensitizing agents. Restorative care will depend on the amount of affected enamel and dentin. Intact enamel can be treated by bleaching or microabrasion. Hypocalcified enamel may require composites, veneers or full coverage restorations. In primary dentition it is essential to maintain adequate arch length which may require composites or full coverage SSC’s. Permanent dentition involves complex treatment with multidisciplinary specialists. Behavior guidance as well as the psychological health of the patient will need to be addressed and managed if necessary.

Dentinogenesis Imperfecta:

-Hereditary developmental disturbance

-May be seen alone or in conjunction with osteogenesis imperfecta

-Frequency of 1 in 8,000

-DI type one associated with COL1A1 and COL1A2 genes

-DI type II and Type III are autosomal dominant linked to 4q12-21 chromosome

Clinical Manifestation:

-Variable blue-gray to yellow-brown discoloration

-opalescent enamel

-frequent enamel fractures with rapid wear and attrition

Three types:

Sheilds Type I - occurs with OI. All teeth in permanent and primary are affected. Bulbous crowns, cervical constriction, thin roots, early obliteration of root canal and pulp chambers. Periapical radioleucencies are common.

Sheilds Type II -also known as hereditary opalescent dentin. Primary and permanent teeth are equally affected. Same radiographic affects as Type I.

Sheilds Type III - Rare. Bell-shaped crowns, shell-like appearance with multiple pulp exposures. Normal thickness of enamel, thin dentin and enlarged pulps.

Management:

Prevention of attrition and rapid wear of dentin is crucial. Early identification and prevention including regular examinations, meticulous hygiene, fluoride and desensitizing agents. Routine restorative treatment in mild to moderate cases with full coverage restorations in severe primary and permanent dentition. Success of full coverage crowns dependent on shape of dentition hoping to minimize cervical fracture. Stabilization and/or replacement of vertical dimension is common. Multiple periapical abecesses may require endodontic therapy included apical surgery. Multidisciplinary approach is essential.

Dentin Dysplasia:

-Autosomal dominant pattern of inheritance

-Affects 1:100,000

Two types

Dentin Dysplasia Type I - (Radicular Dentin Dysplasia: Rootless Teeth)

Normal size crowns in permanent and primary dentition. Amber translucency. Short and constricted roots. Primary teeth have obliterated pulps that fill in prior to eruption. Multiple periapical radioleucencies.

Dentin Dysplasia Type II - (Coronal Dentin Dysplasia)

Normal root lengths. Primary teeth are amber colored with bulbous crowns, cervical constriction, thin roots and early pulp obliteration. Permanent teeth have normal coloration with thistle-tube shaped pulp chambers and multiple pulp stones.

Management:

Prevention of attrition, optimizing esthetics and preventing caries and periodontal disease are of utmost importance. Early identification and prevention including examinations, meticulous hygiene, oral rinses, fluoride and desensitizing agents. Type I may require prosthetic replacements while Type II may be restored with full coverage restorations. Care should be taken for even shallow restorations which could lead to pulpal exposures. Endodontic therapy is guided by root length.

Key Points: Summary:

Early diagnosis, management and prevention are key towards a successful treatment in the above developmental anomalies. Each case is dependent on the individuals classification and clinical manifestations.

Assessment of the Article: Great review of three common developmental anomalies. In all three anomalies mentioned, primary teeth are affected and early diagnosis, management and treatment will be essential for us a pediatric dentist to establish long term success for our patients.

Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell

Resident: Roberts

Date: 3/20/2011

Article title: Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation and or Radiation

Author: Clinical Affairs Committee

Year: Revised 2008

Background:

The most frequently documented source of sepsis in the immunosuppressed cancer patient is the mouth, therefore, early and definitive dental intervention, including comprehensive oral hygiene measures, reduces risk for oral and associated systemic complications.

Recommendations

Examination before initiation of cancer therapy

Two fold objective: 1. to identify and stabilize or eliminate existing and potential sources of infection and local irritants in the oral cavity. 2. To educate the patient and parents about the importance of optimal oral care in order to minimize oral problems/ discomfort before, during, and after treatment and about the possible acute and long term effects of the therapy in the oral cavity and craniofacial complex.

Evaluation should include: type of disease/condition, treatment protocol, medications (including bisphosphonates), allergies, surgeries, secondary medical diagnoses, and immunosuppression status. For Hematopoietic (HCT) patients, include type of transplant, matching status, donor conditioning protocol, and graft versus host disease prophylaxis.

Preventive strategies:

Oral hygeine should include brushing teeth 2x/day with a regular soft nylon brush or electric toothbrush, regardless of the hematological status. Ultrasonic brushes and dental floss should be allowed only if the patient is properly trained. Patients with poor oral hygiene or perio disease may use chlorhexidine daily until tissue health improves or mucositis develops. If mucositis develops then an alcohol free rinse is suggested.

Diet: should be a non-cariogenic diet.

Fluoride: should use fluoride toothpaste and fluoride supplements and gels are acceptable especially if indicated because of xerostomia.

Trismus: Patients who receive radiation therapy to the masticatory muscles may develop trismus. Thus daily stretching should start before treatment and continue throughout to prevent problems.

Hematological considerations:

Absolute Neutrophil Count

>1000/mm3: no need for antibiotic prophylaxis. <1000mm3: defer elective care until the ANC rises.

Platelet count

>75000/mm3: no additional support needed. 40000 to 75000 platelet transfusions may need to be considered, should use supporting agents such as sutures, gel foams etc. <40000: defer care until supportive measures have been taken. Contact physician.

Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures

Resident: Swan
Article Title: Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures
Major Topic: Sedation protocol
Main Purpose: To unify the guidelines for sedation used by medical and dental practitioners, add clarifications regarding monitoring modalities, provide new information from medical and dental literature, and suggest methods for further improvement in safety and outcomes.
Key points from this guideline:
Basic overview of a safe sedation: No administration of sedating meds without medical supervision, careful pre-sedation evaluation for underlying medical or surgical conditions that would increase risk, appropriate fasting for elective procedures, a focused airway examination for large tonsils or anatomic airway anomalies that might increase risk of airway obstruction, clear understanding of the effects of meds used for sedation, along with their drug interactions, hone and practice skills needed for airway management/rescue and for gaining IV access, appropriate medications and reversal agents on hand, sufficient staff to carry out procedure and monitor the patient, a properly equipped and staffed recovery area, recovery to pre-sedation level of consciousness before discharge from medical supervision, appropriate discharge instructions given.
In general: The need for in-office sedation is increasing. Parents are demanding it as it becomes more and more common. Adherence to this guideline won’t, however, guarantee a specific patient outcome. We need to be aware that regardless of the intended level of sedation, sedation always represents a continuum that could result in respiratory depression and loss of the patient’s protective reflexes. Serious risks associated with sedation include hypoventilation, apnea, airway obstruction, laryngospasm, and cardiopulmonary impairment.
The sedation of children is different than sedation for adults. Children in the under-6 age group are particularly vulnerable to the sedating medication’s effects on respiratory drive, airway patency, and protective reflexes. The concept of rescue is essential to safe sedation. Practitioners must have the skills to rescue the patient from a deeper level than that intended for the procedure. Most sedation complication can be managed with simple maneuvers, such as supplemental oxygen, opening the airway, suctioning, and BVM ventilation.
Levels of sedation: Minimal sedation=patients respond normally to verbal commands. Ventilatory and cardiovascular functions are unaffected, although cognition and coordination may be impaired. Moderate sedation=patients respond purposefully to verbal commands (open your eyes) and/or with light tactile stimulation. No intervention needed to maintain airway, spontaneous ventilation is adequate. Deep sedation=patients cannont be easily aroused but respond purposefully after repeated verbal/painful stimulation. Independent ventilation may be impaired and patients may need help maintaining a patent airway. Spontaneous ventilation may be inadequate. Protective reflexes may be partially or completely lost. General anesthesia=not arousable, even by painful stimulation.

--always select the lowest dose of drug with the highest therapeutic index.
--knowledge of each drug’s time of onset, peak response, and duration of action is essential.

Some basic guidelines:
Candidates: ASA class I/II for minimal, moderate, deep sedation. ASA III/IV, special needs kids, abnormal airway patients all require additional consideration. Consult with appropriate subspecialists or anesthesiologist as needed.
Responsible person: Patient needs to be accompanied to and from appt by one, preferably two responsible adults, especially if they’re still in a carseat.
Facilities and Back-up Emergency Services: Practitioners using sedation must have immediately available access to emergency facilities, personnel, and equipment. Protocol for access to back up emergency services must be clearly identified. An emergency cart must be immediately available.
Dietary Precautions: for elective procedures, follow the same fasting guidelines as before general anesthesia. In an emergency situation, balance the risks/benefits.
Documentation:
before sedation: 1. Informed consent 2. Instructions provided to the responsible person (objectives of the sedation and anticipated changes in behavior during and after sedation
at time of sedation: Health evaluation, careful drug history
during sedation: time-based record with name, route, site, time, dosage, and patient effect of administered drugs.
after sedation: time and condition of child at discharge (level of consciousness, O2 sat)
Setting up: SOAPME or SCOMLADI
Monitoring: for moderate sedation, continuous monitoring of O2 sat, HR, intermittent resp. rate/BP. For deep sedation, all the same equipment, plus a precordial stethoscope or capnograph is recommended
For various important tables regarding discharge criteria, ASA classifications, LA doses/duration, drugs and equipment needed for rescue, see actual guideline.
Assessment of Article: Of course it’s a shame we can’t try out the techniques described in this guideline. Without getting hands on experience with deeper levels of conscious sedation, many of the concepts described are foreign. I think it’s good for each of us to take a healthy fear of sedation with us wherever we end up practicing.

Guideline on Pediatric Restorative Dentistry

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center - Providence

Article title: Guideline on Pediatric Restorative Dentistry.

Author(s): Clinical Affairs Committee.

Journal: AAPD Reference Manual.

Year. Volume (number). Page #’s: 2008. 32(6). 187-193.

Major topic: Restorative Dentistry

Overview of method of research: Clinical Guidelines.

Purpose:
To assist the practitioner in the restorative care of infants, children, adolescents and persons with special health care needs.

Methods:
Guideline is based on a review of current literature as well as best clinical practice and expert opinion.

Background:
When restoring the patient’s dentition, the treatment plan should take the following into consideration: developmental status of the dentition, caries risk assessment, the patient’s oral hygiene, anticipated parental compliance and the patient’s ability to cooperate for the procedure. Studies have shown that maxillary primary anterior decay has a direct relationship with primary molar caries. The primary dentition is also highly predictive of caries in the permanent dentition.

Recommendations:

Dentin/enamel adhesives:
Literature supports the use of bonding adhesives when used according to the instructions for that particular product. It shows similar effectiveness in enhancing the retention of restorations, reducing microleakage and sensitivity in primary and permanent dentition. Proper technique is critical for success.

Pit and fissure sealants:
1. Sealants should be placed based on the patient’s caries risk rather than age or time since eruption.
2. Sealants should be placed on high risk surfaces or surfaces that have already experienced incipient lesions. Sealants should be monitored and with proper maintenance have been shown to have 80-90% success rates at 10 years or longer.
3. Prior to sealant placement, proper cleaning of the pits and fissures should take place as should enamoplasty when indicated. Isolation is key.
4. A low-viscosity hydrophilic bonding material layer, either as part of the sealant or beneath it is recommended for long term effectiveness.
5. GIs can be used as a transitional sealant as they have shown a poor retention rate.

Glass ionomer cements:
GIs are useful in children because of their chemical bonding to enamel and dentin, biocompatibility, thermal expansion similar to that of tooth structure, uptake and release of fluoride and decreased moisture sensitivity compared to resin composites.
Recommended uses:
1. Luting cements
2. Cavity base and liner
3. Class I, II, III, and V lesions in primary teeth
4. Class III and V in permanent teeth with high caries risk or cannot isolate.
5. Caries control with high risk patients, restoration repair, interim therapeutic restorations (ITR) where traditional treatment must be postponed or caries control and alternative restorative technique (ART) which serves as a definitive restoration in populations who have limited access to dental care.

Resin-based composites:
Indications- Class I PRRs or 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 extent 1/3-1/2 buccal-lingual intercuspal width and Class III, IV and V as well as strip crowns in primary and permanent dentitions.
Contraindications- difficult isolation with no moisture control, large multi-surface posterior restorations in primary dentition and high-risk patients with multiple caries and poor oral hygiene and compliance.

Amalgam restoration indications:
“In children age 4 or younger, SSCs had a success rate twice that of amalgams.” Amalgams are adequate if enough tooth structure remains to withstand occlusal forces and the tooth is expected to exfoliate within 2 years.
1. Posterior class I and V restorations in primary or permanent teeth.
2. Posterior class II restorations that do not extend past proximal line angles in primary teeth.
3. Posterior class II restorations in permanent teeth.

Stainless steel crown restoration indications:
High-risk patients with anterior caries and or molar caries, extensive decay and multi-surface lesions in primary molars with “strong consideration” for those children treated under GA. SSCs have also been indicated in teeth that are used as space maintainers, when other restorative materials are likely to fail, when cooperation is affected. SSCs can also be used on anterior teeth, several veneered SSCs are available, but may be difficult to adapt and the facing is subject to loss or fracture.

Labial resin or porcelain veneer restoration indications:
Anterior teeth with fractures, developmental defects, intrinsic discoloration and/or other considerations. Porcelain veneers are usually placed on permanent teeth.

Full-cast or porcelain-fused-to-metal crown restoration indications:
Permanent teeth which are fully erupted and gingival margin is at the adult position with developmental defects, extensive loss of tooth structure whether from caries or trauma, completed endodontic treatment, as an abutment for a fixed prosthesis or single tooth implants.

Fixed prosthetic restorations for missing teeth:
Growth must be a consideration when using fixed prosthetic restorations in the developing dentition. They may be used to replace 1 or more teeth to establish esthetics, maintain arch space, to prevent harmful habits and improve function.

Removable prosthetic appliances:
May be used in the primary, transitional or permanent dentition to maintain space, obdurate congenital or acquired defects, provide esthetics, occlusal function or aid in speech development or feeding.

Assessment of Article:
I believe most of us follow these guidelines on a regular basis, but the article had some interesting points and clarified a few grey areas. Good review.

03/23/2011 Guideline on Perinatal Oral Health Care

Resident: J. Hencler
Date: 03/23/2011

Article title: Guideline on Perinatal Oral Health Care
Author(s): AAPD Council on Clinical Affairs
Journal: AAPD Reference Manual V32/NO6 10/11

Type of Article: Review/Reference/Guidelines

Main Purpose:
Propose recommendations for perinatal oral healthcare (POH), including caries risk assessment, anticipatory guidance (AG), preventative strategies, and appropriate therapeutic intervention.

Key points in the article discussion:
The perinatal period begins w/ the completion of the 20-28th wk of gestation and ends 7-28 days after birth. POH is important in the overall health of pregnant women as well as in their baby. Research continues to show links b/t perio disease and adverse outcomes in pregnancy including preterm deliveries, low birth weight, and preeclampsia. Mothers w/ poor OH and high levels of cariogenic bacteria are at risk for infecting their children resulting in a high caries risk at an early age. The primary goal of POH is to reduce and delay for as long as possible caries transmission of S. Mutans (MS). Physicians, nurses, and other health care professional see expectant mother and their infants more often than dentists and should be aware of the infectious etiology and associated risk factors of ECC.

POH and CARIES:
MS colonization of infants has been shown to occur from time of birth. Vertical colonization from mother to infant is well documented. Recent reports have indicated horizontal transmission from siblings may be a concern. The goal of caries risk assessment is to prevent disease by identifying and minimizing causative factors while optimizing protective factors. The early establishment of a dental home by 12 months of age provides critical opportunities to implement OH practices including, a caries risk assessment and to identify and reduce caries risk.

POH and AG:
AG for mothers may help delay the onset and reduce the impact of MS colonization of the infant. AG should include 1) OH education and 2) OHI. Mothers with severe perio disease have high levels of prostaglandins in their gingival crevicular fluid and blood that may be associated w/ uterine contractions leading to preterm deliveries. 3) Diet and nutritional evaluation should be discussed. 4) Daily fluoride should be promoted and 5) routine professional dental care/tx is safest to perform during the second trimester (14th-20th wk). Consult w/ PCP or Ob/Gyn is recommended. Lastly, 6) Delay of MS colonization should be discussed. The dentist should promote reducing maternal MS levels and delaying MS transmission through behavior guidance and preventative OH practices that promote good OH and overall health for mother and child.

Assessment of article: Great review. Guidelines are fun and we need the know them inside and out.

Guideline on the role of Dental Prophylaxis in Pediatric Dentistry

Resident: Adam J. Bottrill
Date: 23MAR11
Region: Providence
Article title: Guideline on the role of Dental Prophylaxis in Pediatric Dentistry
Author(s): Clinical Affairs Committee
Journal: Pediatric Dentistry Reference Manual
Page #s: 141-142
Vol:No Date: 2010
Major topic: Prophylaxis
Minor topic(s): None
Type of Article: Guidelines

Main Purpose: Provide a guideline for the indications for and benefits of a dental prophylaxis in conjunction with periodic infant oral health assessment.

Key points in the article discussion:

I. General:

A. Microbial plaque is the primary etiological factor in caries and periodontal disease. MOST of this plaque can be removed with home hygiene, but MOST patients do not have the necessary skillz to remain plaque-free for long periods of time.

B. Indications:
1. Removal of plaque, stain, and calculus.
2. Elimination of factors that influence the build-up and retention of plaque.
3. Demonstration of proper oral hygiene methods to the pt/caregiver.
4. Facilitation of a thorough clinical exam.
5. Introduction of dental procedures to the child.

C. Type and frequency varies based on individual risk-assessment:
1. MH.
2. Age and cooperation.
3. Compliance.
4. Past and current caries.
5. FH of caries.
6. Past and current perio health.
7. FH of perio health.
8. OH.
9. Plaque.
10. Calculus.
11. Staining.
12. Local factors that would influence the build-up and retention of plaque.

D. Prophy can be performed with TB, cup, floss, instruments.
1. With no stain or calculus, TB is ok.
2. Rubber cup prophy for extrinsic staining and smoothing edges after scaling.
3. Rubber cup using pumice may be used prior to Fl Tx.
4. abrasive toothpastes and pumice may remove pellicle which may increase chances of enamel loss through exposure to dietary acids.
5. Pumice may remove up to 0.6-4.0 microns of outer enamel (includes the Fl-rich layer).

II. Recommendations:

A. Periodic Prophy should be performed to:
1. Instruct.
2. Remove plaque and calculus.
3. Polish hard surfaces.
4. Remove staining.
5. Facilitate the exam.
6. Introduce dental procedures to young children and apprehensive patients.

B. Practitioner should choose the least aggressive technique that fulfills the goals of the procedure. Least abrasive paste with light pressure.

C. If pumice or course past is used, Fl application indicated.

D. Patients at higher risk should have prophy at more frequent interval than 6 months.
1. Allows for OH monitoring and frequent Tx.

E. Individualized Tx plans are necessary.

Assessment of Article: Short and sweet and common sense. I suppose the AAPD needs to have this guideline, but it seems silly. I'm glad they didn't waste more than 2 pages.

3/23/11 Guideline on Fluoride Therapy

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Guideline on Fluoride Therapy
Author(s): Council on clinical affairs
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2008.
Major topic: Fluoride
Overview of method of research: Medline search using the words Fl, fluoridation, acidulated phosphate fl, fl varnish, fl therapy, and topical fl.
Findings:
Fl has many caries protective mechanisms of action including remin and altering bacterial metabolism. Daily Fl through water supplies and use of Fl toothpaste are effective preventive procedures. Sources of dietary Fl include tap h20, infant formula, prepared food, soda, juice, and toothpaste. Formulas have varying degrees of Fl. Fluorosis results from cumulative Fl intake during enamel development depending on dose duration, and intake time.
Professionally applied topical Fl is good for moderate to high-risk patients. 2% NaF(9000ppm), 1.23% APF(12,300ppm) solution and gel, and 5% NaFV(22,500ppm) are commonly used. Recommended treatment time is more than 4 minutes.
After determining a child’s exposure to Fl, systemic Fl may be necessary. Keep in mind that we get Fl from numerous vehicles, and prescribing Fl may cause future fluorosis. Use the famous Fl table to determine what dosage the child needs. The child should suck or chew the tablets to optimize topical benefits.
Professionally applied Fl should be based on caries risk. Prophy w/ pumice is not essential. Ensure the child does not swallow any of the Fl. Low risk patients should be seen every 6 months, moderate to high risk patients every 3-6 months.
Therapeutic use of Fl at home should focus on maximizing topical contact in low dose high frequency regime. Fl toothpaste should be used twice daily, as it has shown t be more effective than one time daily. Children 2< should use a smear of toothpaste, and pea size amount for children age 2-5. Rinsing after brushing should be avoided. High risk patients should be prescribed toothpastes with a higher Fl concentration.

Key points/Summary: Fl is da bomb. All of this stuff and more will be on the boards.

Assessment of Article: AAPD guideline. Know it. Cherish it. Do it.

Guideline on Behavior Guidance for the Pediatric Dental Patient

Resident: Roberts

Date: 3/24/11

Article: Guideline on Behavior Guidance for the Pediatric Dental Patient

Author: Clinical Affairs Committee - Behavior Mangement Subcommittee

Journal: American Academy of Pediatric Dentistry

Year: 2008 Revision

Behavior guidance is based on scientific principles but requires skills such as communication, empathy, coaching, and listening. It is an art form built upon a foundation of science. The goals of behavior guidance are to establish communication, alleviate fear and anxiety, deliver quality dental care, and build a trusting relationship between dentist and child. All decisions regarding use of behavior guidance techniques must be based upon a benefit vs. risk evaluation.

Various techniques include:

Tell - show - do: This technique involves demonstrations and verbal explanations of the procedure in phrases appropriate to the developmental level of the patient.

Voice control: This involves altering the voice by volume, tone, and pace in order to direct patient behavior.

Nonverbal communication: This is guidance through appropriate contact, posture, facial expression, and body language.

Positive reinforcement: Positive reinforcement is rewarding desired behavior and thus strengthening the recurrence of those behaviors. May include voice modulation, facial expression, verbal praise, appropriate physical contact, tokens and toys.

Distraction: This is the technique of diverting the patients attention away from what may be perceived as an unpleasant procedure. May include, verbal language, contact, inanimate objects such as a t.v.

Parental presence: The presence or absence of the parent sometimes can be used to gain cooperation for treatment

Nitrous oxide: Nitrous Oxide can be used to reduce anxiety and increase effective communication. It is an inhalation anxiolytic/ analgesic agent.

Protective stabilization: can be used for special needs patients or situations where the benefit of completing a procedure outweighs the risk of damage to the developing psyche of the individual. Protective stabilization can decrease risk of injury while allowing safe completion of treatment. It should not be used with patients with a compromised airway or and a practitioner should be cautious when using medications that can cause depressed respirations.

Sedation: can be used on patients who are unable to receive care due to age, mental, physical or medical limitations. Various forms and methods exist depending on desired level of sedation: mild, moderate, deep sedation and General Anesthesia.

Conclusion/Assessment: Without extreme detail this article is a reminder that as pediatric dentist are goals to treat a patient should align with our duty to develop the psyche of the individual so that our patients become conditioned to a positive and appropriate experience. This article briefly outlines the various methods by which we can accomplish this task and was a good review.

Guideline on Use of Nitrous Oxide for Pediatric Dental Patients

Resident: Cho

Author(s): Council on Clinical Affairs

Journal: AAPD Reference Manual

Year. Volume (number). Page #’s: 2010-11

Major topic: Nitrous Oxide

Type of Article: Reference Article

Main Purpose: To assist the dental profession in developing appropriate practices in the use of nitrous oxide for pediatric patients.

Methods: A MEDLINE search was conducted using the terms “nitrous oxide”, “analgesia”, “anxiolysis”, “behavior management”, and “dental treatment”.

Key points/Summary:

Background:

Nitrous oxide is a colorless and virtually odorless gas with a faint, sweet smell. It is an effective analgesic/anxiolytic agent causing CNS depression and euphoria with little effect on the respiratory system. It is relatively insoluble, passing down a gradient into other tissues and cells in the body, such as the CNS. It is 34 times more soluble than nitrogen in the blood.

Objectives of nitrous oxide:

Reduce or eliminate anxiety, reduce untoward movement and reaction to dental treatment, enhance communication and patient cooperation, raise the pain reaction threshold, increase tolerance for longer appointments, aid in treatment of the mentally/physically disabled or medically compromised patient, reduce gagging, potentiate the effect of sedatives.

Disadvantages of nitrous oxide:

Lack of potency, dependent largely on psychological reassurance, interference of the nasal hood with injection to anterior maxillary region, patient must be able to breathe through the nose, nitrous oxide pollution and potential occupational exposure health hazards.

Patient selection:

A fearful, anxious, or obstreperous patient

Certain patients with special health care needs

Gag reflex interferes with dental care

Patient for whom profound local anesthesia cannot be obtained

Cooperative child undergoing lengthy procedure

Review of medical history should be performed prior to decision to use nitrous oxide.

Contraindications for nitrous oxide:

Chronic obstructive pulmonary disease

Severe emotional disturbances or drug-related dependencies

First trimester of pregnancy

Treatment with bleomycin sulfate (drug used to treat cancer)

Methylenetetrahydrofolate reductase deficiency

When considering patients with significant medical conditions (ex. severe obstructive pulmonary disease, CHF, sickle cell disease, acute otitis media, recent tympanic membrane graft, acute severe head injury), physician should be consulted.

Techniques for nitrous oxide:

Flow rate of 5 to 6L/min generally acceptable – flow rate should be adjusted after observation of reservoir bag. Introduction of 100% oxygen for 1-2 minutes followed by titration of nitrous oxide in 10% intervals is recommended. The concentration of nitrous oxide should not routinely exceed 50%. The effects of nitrous oxide is largely dependent on psychological reassurance, therefore, it is important to still continue traditional behavior guidance techniques during treatment. Diffusion hypoxia may occur (as a result of rapid release of nitrous oxide form the blood stream into the alveoli, thereby diluting the concentration of oxygen – leading to headache and disorientation), therefore, 100% oxygen for 3-5 minutes must be given at the end of the appt. Patient must return to pretreatment responsiveness before discharge.

Monitoring:

Clinical observation of patient’s responsiveness, color, RR, and rhythm must be performed. Spoken responses provide an indication that the patient is breathing.

Adverse effects of nitrous oxide:

Nitrous oxide has an excellent safety record. Most common adverse effect is nausea/vomiting, which occurs in 0.5% of patients. A higher incidence is noted with a longer administration of nitrous oxide, fluctuations of nitrous oxide levels, and increased concentrations of nitrous oxide.

Fasting is not required before nitrous oxide. However, the dentist may recommend only a light meal be consumed 2 hours prior to nitrous oxide.

Informed consent must be obtained from the parent. The patient’s record should include indication for use of nitrous oxide, flow rate, duration of the procedure, and post treatment oxygenation procedure.

Facilities:

All newly installed facilities for delivering nitrous oxide must be checked for proper gas delivery and fail-safe function prior to use. Inhalation equipment must have the capacity for delivering 100% oxygen and never less than 30% oxygen. The equipment must have an appropriate scavenging system. Proper BLS training is required for all personnel using nitrous oxide and an emergency kit must be readily accessible. A positive-pressure oxygen delivery system capable of administering >90% oxygen at a 10L/min flow for at least 60 minutes must be available. There should be documentation that all emergency equipment and drugs are checked and maintained on a regularly scheduled basis.

Assessment of Article: I was surprised that the article did not mention the use of blood pressure cuffs and pulse oximeters for monitoring the patient when using nitrous oxide. Great article!