Pharmacological Management of the Pediatric Patient

Resident: Adam J. Bottrill
Date: 19JAN11
Region: Providence
Article title: Pharmacological Management of the Pediatric Patient
Author(s): Wilson, Stephen DMD, MA, PhD
Journal: Pediatric Dentistry
Page #s: 131-135
Vol:No Date: 26:2, 2004
Major topic: Behavior Management, Sedation, General Anesthesia
Minor topic(s): NA
Type of Article: Conference Paper

Main Purpose: Provide an overview of the various forms of pharmacological management of pediatric dental patients.

Key points in the article discussion:

I. General:

A. Society demands not only efficient, but HUMANE ways of administering behavior management.
B. Only ONE behavior management technique is consistently taught at ALL residency programs in the US... Pharmacological Management (PM).
1. PM is generally divided into two categories: Sedation and GA.
2. Hundreds of articles written about sedation... much less about GA.
C. Factors to be considered when considering PM.
1. Risks
2. Safety Record
3. Extent of dental needs
4. Practitioner competence
5. Professional support for technique
6. Monitoring
7. Cost
8. Venue
9. Parental expectations
10. Child's needs and personality
11. Integration of these factors into MO embraced by profession

II. Sedation Risks and Safety.
A. Major: brain damage and death
B. Minor: vomiting, behavior, extreme physiological parameters
C. COMPLETE med history is imperative.
1. airway issues (snoring etc...)
2. allergies
3. review of systems
4. Only children with very MILD conditions should be considered for sedation.
D. AIRWAY AIRWAY AIRWAY
E. Though pediatric patients have died due to sedation, there is no evidence that suggests death has occurred when practitioners are faithfully following guidelines.
F. It is NOT POSSIBLE to accurately calculate an official safety record WRT sedation. There is no way to generate an accurate number of SUCCESSFUL sedation attempts.

III. PM Cost and Reimbursement issues

A. Significant issue effecting choice of sedation
B. Medicaid covers enough to "break even" in most states.
C. GA is OFTEN covered for "equivalent" medical procedures.
D. So why the disparity???

IV. Training Issues

A. Risk may INCREASE with sedation (when compared to GA) due to lack of training or adherence to sedation guidelines.
B. Dental students are often not trained in deep sedation techniques due to the lack of knowledge and experience of faculty.
C. There seems to be a general attitude of "It won't happen to me" among dentists using sedation.
D. Solutions: MORE TRAINING, Resolution of the financial/political issues associated with GA

V. Professional Issues

A. Subtle professional pressures by medical anesthesiologists for the independence in the roles the roles of operator and anesthetist.
B. The author blames "financial considerations".
C. 2 or more sedation cases costs MORE than one GA case.
D. Controversy over HOM and "voice control"
E. General disagreement and lack of communication between AAP, AAPD and medical anesthesiologists.

VI. Societal and Parenting Issues

A. Parents no longer implicitly trust practitioners
B. Parental expectations are sometimes rediculo.
C. Recent surveys of AAPD members have shown that the general perceived behavior of children has deteriorated over the last few decades.
1. This correlates with the general increase in the necessity of sedation over the past few decades.

VII. Conclusions

A. GA for the healthy fearful child is extremely safe.
B. Some medical specialists are opposed to use of GA outside of the hospital however "little evidence supporting such an opinion is available."
C. PM of the pediatric patient is acceptable and desirable.
D. What is needed:
1. MORE RESEARCH ENDEAVORS
2. Dissemination of accurate information to communities
3. Collaboration of medical and dental organizations.
4. Political and business initiatives.
5. Further efforts to minimize dental disease.

Assessment of article: I'm not a huge fan of the "Conference Paper." Very opinionated and anecdotal. Not really of much use clinically.

The use of imagery suggestions during administration of local anesthetic in pediatric patients.

Resident: Adam J. Bottrill
Date: 18SEP09 Region: Providence
Article title: The use of imagery suggestions during administration of local anesthetic in pediatric patients.
Author(s): Peretz B., Bimstein E.
Journal: Journal of Dentistry for Children
Volume #; Number; Page #s: July-August pp: 263-267
Year: 2000
Major topic: Behavior management
Minor topic(s): Hypnotism
Type of Article: Experimental study.

Main Purpose: To evaluate the effect of suggestion in a group of children before and during the receiving of a local anesthesia injection. Also, efforts were made to correlate these reactions with social and dental treatment variables.
Overview of method of research: Controlled study of effect of behavior management technique.
Findings: Not telling

Key points in the article discussion:

A. General: It is generally agreed upon that the most stressful time of a dental visit, for both patient and dentist is the administration of anesthesia (to a child).
1. “suggestion” is the main component in hypnosis
2. Found that the pulse rates of hypnotized children decreased and observed levels of crying were less intense.
3. Hypnosis is found, in general, to be more effective on younger children. It has been suggested though, that it not be used on those younger than 7 y.o.
4. Suceptability to suggestion:
a. females more than males
b. younger more than older
c. children of lenient parents more than children of strict parents.

B. Materials and Methods:
1. 80 children, age 3-16
2. All required anesthesia administration
3. Treated by one of two dentists:
4. Pre-data collected:
a. general behavior (relaxed, tense, highly tensed)
b. previous behavior (cooperative, uncooperative but allowing tx, uncooperative and didn’t allow tx)
c. mode of previous behavior management (non-pharmacological, nitrous, premed with nitrous, GA)
d. previous traumatic medical or dental treatment.
5. Behavior measured at current appt using previous measurements
6. Younger children told tooth was “going to sleep”, older children told the tooth would be “anesthetized”.
7. Before administration, all children was asked to think of their favorite pleasant image. Those who could not think of one were asked their favorite game/pet etc…
8. Throughout injection procedure, operator provided comments reinforcing the pleasant image.
9. Data collected:
a. whether they used the same image throughout, facial expressions, eye movement, body tonus.
10. Chi-square used for variable comparison, t-test used for boys vs. girls.

C. Results:
1. Mean ages: 5.3 boys, 7.2 girls
2. Nearly a third of the patients had previous dental/medical traumatic experiences.
3. 60% maxillary
4. 53% demonstrated facial pleasure, 31% indifferent, 16% dislike
5. 81% were “relaxed”
6. No gender difference found WRT eye movement, facial expression or body tonus.
7. Most children were able to maintain the images throughout procedure and most kept their eyes closed.
8. Those treated with nitrous or oral sedation were more able to maintain images.

D. Discussion:
1. Most children could conjure up images.
2. Boys (pets) were different than girls (nature) at what type of image they selected.
3. Present study agreed with previous studies that suggested younger patients are more susceptible to suggestion.
4. The request to “fantasize is a relaxation tool. The child is allowed to go into a light “trance.”
5. Good rapport is essential to this process.
6. Though many dentists use the power of suggestion intuitively, the findings of this study should encourage the routine and deliberate use of this technique.

E. Conclusions:
1. Visualization suggestions may be effective in children from the age of three.
2. The utilization of the child’s imagination is a baluable behavior management adjuvant during dental treatment.
3. Nitrous oxide enhances the children’s capacity to accept and retain images..

Assessment of article: Don’t we all sort of do this already? Seemed like a first year pedo resident project, but better organized. Shenanigans?

Expanding child behavior management technology in pediatric dentistry: a behavioral science perspective.

Resident: Adam J. Bottrill
Date: 11SEP09 Region: Providence
Article title: Expanding child behavior management technology in pediatric dentistry: a behavioral science perspective.
Author(s): Kuhn, Brett
Journal: Pediatric Dentistry
Volume #; Number; Page #s: Volume 16 pp: 13-17
Year: 1994
Major topic: Behavior management
Minor topic(s): Technology
Type of Article: Discussion

Main Purpose: Discuss issues relevant to incorporating new behavior management technology into the dental school curriculum and disseminating it to practicing dentists.
Overview of method of research: Discussion
Findings: More research needed.

Key points in the article discussion:
A. General: Behavior management is as fundamental to the successful treatment of children as are hand piece skills and knowledge of dental materials.
1. Disruptive behavior leads to increased delivery time, risk of injury to the child.
2. AAPD’s 10 endorsed behavior management methods in 1991:
a. voice control
b. TSD
c. positive reinforcement
d. distraction
e. nonverbal communication
f. hand-over-mouth
g. phsycal restraint
h. conscious sedation
i. nitrous oxide
j. GA
3. A lot has changed over the years WRT appropriate behavior management practices.
a. traditional behavioral techniques don’t always work
b. changes in community standards have resulted in objection to HOM, restraints and pharmacological intervention.
c. changes in legal and ethical standards have made some dentists hesitant to use some techniques.
4. The result is a lot more dentists currently open to new, non-invasive behavioral management techniques.
5. The answer may lie in a collaborative effort between dentists and behavioral psychologists.
6. The 3 discussed techniques were chosen based on initial research efficacy with pediatric patients.
a. non-intrusive
b. non-cumbersome
c. conceptually fit well along-side current techniques
B. Contingent Distraction:
1. Diverting a child’s attention and engaging them in alternative activities like watching TV, playing video games or listening to audio tapes (music or stories).
2. Making this distracter’s availability contingent upon cooperative behavior. Immediate termination of distracter at first sign of uncooperative behavior.
3. Initial studies reveal that this may be an effective, yet practical means of reducing problem behavior.
C. Live Modeling:
1. Permitting children to observe other children adaptively undergoing dental treatment is an effective way of preparing them to accept treatment and demonstrate what’s expected of them.
2. Decreases in disruptive behavior can also be produced by simply having a child observed by peers (peer pressure).
3. One other option is to show I video of a cooperative patient.
4. This wil need to be analyzed across a wide range of patient-types… cooperative to uncooperative.
D. Contingent Escape:
1. Instilling a sense of trust and control is important.
2. In the past, the “raised hand” technique could give the child this sense of control.
3. Often, disruptive behavior results in halting of the procedure… which reinforces the behavior.
4. In this procedure, brief periods of “escape” from the ingoing dental treatment are provided contingent upon good behavior. Disruptive behavior delays escape from the treatment.
5. I can actually see this form of contingent reward as a problem… especially if the child simply won’t allow the procedure to proceed.
6. Preliminary studies show great success with this procedure when implemented early and consistently in the treatment.
7. Further research needed to figure out how to train dental students on this method.
E. Conclusions:
1. Collaboration between dental and behavioral scientists has been encouraged by the AAPD and viable alternatives have begun to be developed.
2. More research is needed on all fronts to more firmly establish treatment parameters, curriculum changes etc…
3. It is important to note that these techniques serve to SUPPLIMENT, not replace existing behavioral management techniques.

Assessment of article: Seemed more like loose opinions rather than science. But I’ll let it slide because the topic interests me. "Need more IIIIIINPUT" (Johnny Five style)

The Changing Nature of Parenting in America

Department of Pediatric Dentistry

Lutheran Medical Center

Resident’s Name: Kris Hendricks Date: September 11, 2009

Article title: The Changing Nature of Parenting in America

Author(s): Nicholas Long, PHD

Journal: Pediatric Dentistry

Volume (number): 26:2

Month, Year: 2004

Major topic: Parenting Styles

Minor topic(s):Behavior Management

Type of Article: Professional Opinion

Main Purpose To discuss how changes in parenting styles affect the practice of pediatric dentistry.

Overview of method of research: Mostly professional opinion with some references to the scientific literature.

Findings: Most board certified pediatric dentists feel that parenting has taken a turn for the worse. They also feel that children display worse behavior now than they did in the past and that this has negatively affecte the practice of pediatric dentistry. Many blame these behavioral changes on changes in parenting, but it is important to realize that parenting takes place within the context of society and that societal changes play a significant role in child outcomes, perhaps even more significant than parenting.

Key points/Summary : Americans are almost as fixated with child rearing as we are with sex. The problems facing children today are much more severe than those facing children in the "Leave it to Beaver" era. Drugs, suicide, violence and teen pregnancy are just a few of the problems that children are facing these days. The media suggests that these problems are the result of poor parenting.

A recent survey of diplomats of the AAPD (sounds like a bunch of cranky old men) found that parents today are much less willing to allow their kids to suffer pain at the hand of the dentist. Traditional behavior management techniques like hand over mouth are no longer acceptable. 43% of them say this has decreased satisfaction in the practice of pediatric dentistry.

There is still some debate as to how much parenting matters in the outcome of children. But most researchers believe it to be important. Society, however, has a very significant influence on children. It is especially important for us to be careful in our judgement of parenting and also not to apply Anglo-American parenting values on other cultures.

Assessment of article: This was an interesting read. The survey of the AAPD diplomats sounds like they're really missing the good old days. I was particularly impressed by the suggestion that we should not apply "our" concept of good parenting on other cultures and act judgmentally. Most of our patients come from a very different culture than myself and I'm easily tempted to judge them by my values.