Pediatric Dentistry

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Pediatric Dentistry

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Introduction
Chapter 1
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1 Definition

• What is Pediatric Dentistry

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Definition

• An age-defined specialty that provides both
  primary and comprehensive preventive and
  therapeutic oral health care for infants and
  children through adolescence, including those
  with special health care needs

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Who ?

• infants and children through adolescence
• including those with special health care needs

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What?

• provides both primary and comprehensive
  preventive oral health care
• provides both primary and comprehensive
  therapeutic oral health care

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2 key elements

• age-defined
• primary and comprehensive...care
• "infants and children through adolescence"
• "special health care needs"

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age-defined

• Most specialties procedure defined

• PD no limitation to
• treatment they provide

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• Pediatric dentists are primary providers. There
  is no need for a referral of patients

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• Pediatric dentists see patients at any age from
  birth up to their late teens

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• Pediatric dentists have the training and
  experience to evaluate and treat patients being
  medically compromised.

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key elements

• age-defined
• primary and comprehensive...care
• "infants and children through adolescence"
• "special health care needs"

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3 Structure of the dental consultation
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• Greeting
• Preliminary chat
• Examination
• Preliminary explanation
• Business
• Health education
• Dismissal

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3.1 Greeting

• 3.1.1 in a friendly way
• 3.1.2 by name
• Dont proceed too quickly

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3.2 Preliminary chat

• Begin with non-dental topics
• Ask an open qustion
• Listen to the answer

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3.3 Examination

• Should be pain-free
• Should be adequate
• Should not be totally tooth-centered

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3.4 Preliminary explanation

• The aim to explain what the clinical or
  preventive objectives are

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• In terms parents and children will understand.
  
• This is a vital part of any visit

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3.5 Business

• 3.5.1 Remain in verbal contact
• 3.5.2 Check the patient not in pain

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• a) Discuss what you are doing
• b) Use the patients name to
• show a personal interest
• c) Clarify misunderstandings

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• 3.5.3 Summarize what has been done at the end
• 3.5.4 Offer aftercare advice

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3.6 Health education

• Give advice on maintaining a healthy mouth
• The final part is goal setting
• Goal setting must be used sensibly.

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3.7 Dismissal

• The final part of a visit
• Should be clearly signposted
• Should be ensured the patient and parents leave
  with a sense of goodwill.

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Structure of the dental consultation

• Greeting
• Preliminary chat
• Examination
• Preliminary explanation
• Business
• Health education
• Dismissal

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4 Anxious and uncooperative children

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• 4.1 Dental anxiety is a common problem all over
  the world, especially in pediatric dentistry

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• It not only prevents patients from seeking care
  but also cause stress to the dentists

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• Dental anxiety is a problem that we as a
  profession must take seriously

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4.2 How does the dental anxiety develop?
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• 4.2.1 Be afraid of pain or imaginary pain

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• 4.2.2 Uncertainty about what is to happen is
  certainly a factor

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• 4.2.3 A poor past experience with a dentist
  could upset a patient

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• 4.2.4 Learn anxiety response from parents,
  relations, friends, or books,TV show

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4.3 The extent of dental anxiety
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• it is no easy task to measure dental
  anxiety and pinpoint aetiological agents

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• 5 Helping anxious patients to copy with dental
  care

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• Establish an effective preventive programme
• Establish good dentist-patient relationship

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• Ensure any treatment is pain-free
• Manage time effectively
• Behavior Management

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Behavior Management

• Adversive Techniques
• Physical restraint
• Hand over mouth
• Pharmacologic Techniques
• Sedation
• General Anesthesia

• Traditional Techniques
• Tell-show-do
• Distraction
• Modeling
• Positive Reinforcement
• Voice control

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Behavior Management

• Pharmacological agents
• Pharmacological-alternatives

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Behavior Management

• Adversive Techniques
• Physical restraint
• Hand over mouth
• Pharmacologic Techniques
• Sedation
• General Anesthesia

• Traditional Techniques
• Tell-show-do
• Distraction
• Modeling
• Positive Reinforcement
• Voice control

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TSD Technique

• T Tell
• S Show
• D Do

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• A Tell Explanation of procedures at the right
  age/educational level

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CHOOSE WORDS CAREFULLY
For Most Children

• AVOID
• Shot
• Needle
• Hurt
• Pull
• Etc.

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• B Show demonstrate the procedure
• C Do following on to undertake the task.

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Positive reinforcement

• Find something to praise
• Anything
• Stress accomplishments
• Prizes at end of visit

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Adaptive method
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Modeling

• Modeling could be used
• to alleviate anxiety due
• to fear of the unknown

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Live modeling
Next patient watches
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• Its not necessary to use
• a live model, videos of
• co-operative patients
• are of value.

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Cognitive approaches

• Asking patients to
• identify their negative
• thoughts

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• helping patients to recognize their negative
  thoughts and suggesting more positive
  alternatives reality based

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Distraction

• Shift attention from the dental setting towards
  some other kind of situation.

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Distraction

• Conversation
• Mirror
• Book
• Electronics
• Whatever

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Voice control

• Tone or inflection
• Volume
• Soft and even
• Loud and abrupt
• Use to hold childs attention
• Do not telegraph frustration

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Parental presence?

• Supportive for very young patients
• Instructive for parents
• Parent is silent partner
• Never interpreter of same language
• Dont threaten departure

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Parental interactions
Parents should be told where they should stand
(sit), what they can say, and how they should
react without threats or condescension.
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Uncooperative Patient

• Explanation
• maintain confidence
• Direct attention to child
• Speak directly
• Parental presence
• Silent assurance
• Positive reinforcement
• Persist

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Time Out

• Pause for reflection
• May assist the dentist
• Test of stamina
• Economically difficult

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Restraints

• Mouth Prop
• Parental security
• Wraps or Papoose Board
• Hand over mouth

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Mouth prop

• Support oral access
• Treatment aid
• Apply with care
• Not to impinge on lips
• Not to subluxate mandible
• May be interpreted as restraint

• Assure ratchet works
• Open slowly
• Dont impinge on lips
• Do not use as a crow-bar

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Physical restraint

• Parent may be more supportive than wrap
• Wraps/Boards
• Pediwrap, Papoose Board
• Supports physically challenged patients
• Necessity during sedation
• Downside
• Sense of helplessness, loss of control
• Avoid injury
• Assure parental informed consent
• Meet community standards

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When to consider pharmacologic management...
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Nitrous Oxide Analgesia

• Adjunct to non-pharmacological management
• Assumes a minimal level of cooperation
• Child must be capable of following instruction
• Capable of sitting alone in chair
• Capable of breathing through the nose
• Nasal inhaler hood must fit properly

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Sedation

• Definition of Conscious Sedation
• Minimally depressed level of consciousness that
  retains the patients ability to maintain a
  patent airway independently and continuously and
  to respond appropriately to physical stimulation
  and/or verbal command

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Sedation

• Strict guidelines requiring
• Monitoring recording
• Recovery area
• Additional personnel

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Functional Levels of Sedation

• I Anxiolysis
• II Interactive
• III Non-interactive, arousable with
  mild/moderate stimuli
• IV Non-interative, non-arousable except with
  intensive stimulus
• V General Anesthesia

Conscious Sedation
Deep Sedation
General Anesthesia
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Conscious sedation (I,II,III)
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General Anesthesia

• Last resort
• Indications
• Immaturity
• Extensive caries
• Physical or mental challenge
• Definition
• Induced state of unconsciousness accompanied by
  loss of protective reflexes, including the
  ability to maintain an airway independently and
  respond appropriately to physical stimulation
  and/or verbal command

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Management entree selection

• Most patients require simple management
  techniques
• A small cohort require the more aggressive
  management techniques
• Advance preparation further minimizes necessity
  for aversive techniques

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Number of children who actually present as
management problem???

• Estimated that 22 actually present moderate -
  severe management challenges

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Management Technique Utilization

• Curve moves left with increasing age
• General anesthesia more likely to be utilized
  below the age of 2.5 yrs

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Successful Patient Management

• Goal Safe, effective and quality dental care
• Significant resources are required

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Successful Patient Management

• Good communication with patients and parents to
  establish expectations and mitigate
  misunderstanding
• Patients recognition of their own
  accomplishment, without dreading the next visit
• Parents recognition of the dentists
  accomplishment and an understanding of what will
  be necessary to complete future visits

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6 First dental visit

• There seems to be a lot of confusion about the
  correct timing for the first dental visit.

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6.1 The correct time

• The AAPD recommends within 6 months of the
  eruption of the first primary tooth and no later
  than 12 months of age

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• A child should have his or her first dental visit
  at the first birthday!

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6.2 Medical and dental record

• The dentist should record a thorough medical and
  dental history.

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6.3 oral examination

• Usually be accomplished with the parent present
  in the office.
• The child patient may be sitting in knee-to-knee
  position

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6.4 Assess

• 6.4.1 Assess the risk of oral and dental disease
• 6.4.2 Evaluate the child's oral and dental
  development

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• 6.4.3 Evaluate the need for fluoride
  supplemen-tation.

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• 6.4.4 It may be important to discuss
  non-nutritive habits, injury prevention, oral
  hygiene, and effects of diet on the dentition.

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6.5 Treatment

• If treatment is indicated the dentist should be
  prepared to provide therapy or he needs to refer
  the patient.

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