10/21/15 11:33 AMPed Competencies:

4 sealants 2 pt comp exams 1 class II primary molar (amalgam or composite) 1 SSC primary molar 1 nitrous sedation 1 diagnosis, tx plan &/refer space management 1 experience with special needs

Examination of the Mouth and other Relevant StructuresProfessional Oral Health Intervention

Periodicity depends on needs & risk factors Anticipatory guidance and counseling 1st exam @ eruption 1st tooth; build “dental home”

Components of Comp Exam General health/growth Pain Extraoral soft tissue TMJ Intraoral soft tissue Oral hygiene and perio Intraoral hard tissue Developing occlusion

Caries risk Behavior

Posture The further forward the child leans his head, the more weight he bears Head forward – compression of nerves in neck and spine Normal: 4-9 mm

Muscles Mm involved in breathing Mm involved in masticatory system Mm of the neck Mm of the back (sup and inf) Range of movement – cervical

o Masseter Elevates (closes) mandible

o Temporalis Both ant and post together Eeevates mandible Anterior portion protrudes Posterior portion moves jaw back (retrusion)

o Temporal tendono Lateral pterygoid

Superior – retrusion and ipsilateral movement, opening Inferior – opening (ONLY one that does this, protrusion, contralateral

jaw movemento Medial pterygoid

Elevates and moves mandible forwardo Sternocleidomastoid

Unilateral – rotate head to opposite side Bilateral elevated head

o Trapezius Elevates, depresses, rotate, reflects shoulder blade

Extraoral ExamCentric Relation

Adequate position Reslaxed muscles Independent from the teeth Pure rotations Position can be repeated

Reduction, “Clicking” On opening, an early click is ok, late click is bad On closing, an early click is bad, late click is ok

Intraoral ExaminationCentric OcclusionPrimary Dentition (Flush, M Step, D Step)

Distal Step – 10%Flush terminal plane – 30%Mesial Step – 60%

Baume’s 3 factors for Class I adjustment 1. Mesial growth of mandible2. Early mesial shift-closure of generalized posterior spacing with eruption of 1st

permanent molars3. Late mesial shift drift of mandibular 1st perm molars into leeway space

Dental Arch/Occlusal Development from Infant to Adolescent Class I (61.6%), Class II (34.3%), Class III (4.1%) Distal step Class II Flush Terminal plane Class I (56%), Class II (44%) Mesial step Class I (mostly), Class II Excessive M step Class III

Centric Occlusion – see page 11/12 for photosPrimary dentition

Overbite:o Normal = 10-40%

19% - ideal 27% - reduced 24% - openbite 20% - excessive

Overjeto Ideal = 0-4 mm

28% - ideal 72% - excessive

Moorrees Longitudinal Studyo Studies degree of overbite and how this changes as patient gets older.. there is

no clear pattern (pg 12)o Available Space-Incisor Segment

On average 1.6 mm less space available for the permanent mandibular incisors than would be needed for ideal alignment

Primary Dentition: Spacing Primate spacing (Max: D to laterals, Man: D to canines)

o Baume: closes with early M shifto Clinch: closes with eruption and drift of lateral incisors

Generalized spacingo Leighton study:

Incisor Liability (Moyne)

Ideal Primary Dentition Occlusion M step molars and canines Generalized and primate spacing 2 mm overjet 2 mm overbite (30%)

“Ugly Duckling Stage” – when the canines are erupting, tend to flare laterals in the process (temporary)

Factors affecting approach to incisor liability

Teeth size Spacing primary dentition Intercanine width growth Archlength increase due to more labial positioning of permanent incisors Size differential b/w primary molars and premolars (leeway space)

Summary of Arch changes Maxilla

o Slight increase in archlength due to labial position of incisors and increased intercanine width

Mandibleo Loss of posterior archlength due to space closure (generalized and “E” space)o Slight increase in anterior archlength due to labial position of incisors and

increased intercanine widthAirways

Nose breathers can become mouth breathers This change can have big consequences

Facial changes – pg 16

RadiographsShould I take X-Rays?

Timing of initial radiographic exam should not be based upon the patient’s age, but upon each child’s individual circumstances

Rx should be taken only when there is an expection that the diagnostic yield will affect pt care

Types: PA, BW, Occlusals, Pan, lateral/frontal ceph, others

Initial Exam Primary dentition

o BW, if no direct view Mix Dentition

o BW and pan Permanent

o 4 BWRecall Pt

DMF or High risk pto BW

Primary & mix dentition every 6 months or until no evidence of caries Permanent every 6-12 months

No DMF or low risk pto BW

Primary & mix every 12-24 months Permanent every 18or 24 months

Periodontal dso Complete series of PA’s and BW’s

Precautions Every precaution should be taken to minimize radiation exposure, protective thyroid

collars and aprons should be used whenever possible. This practice is strongly recommended for children, women of childbearing age, and pregnant women.

TREATMENT PLANNINGReview Standard of care recommendations

Risk assessment Ongoing risk assessment

o CRA form/CAT toolo Diagnostic codes

Risk assessment CODES (pg 20) Biofilm and biomarkers How to monitor caries

o Diagnodent – to check remineralization – NOT TO TW Early diagnosis 500 microns demin DO BACTERIAL COUNT at 6 months age

ISOLATION Rubber dam, punch one big hole, stretch over ~4 teeth

Restorative Materials Composites, amalgams, cements, veneers, crowns, pediatric crowns

High vs Low speed No literature that proves high better than low High speed best for enamel Low speed for dentin (low speed can break enamel structure) Indirect pulp cap better than removing all decay and exposing pulp

W/ water vs W/o water Better with water

Isolation vs no isolation Always use, except in sealants sometimes to avoid anesthesia

Bottle vs unidose No significant difference

Carbide vs diamond Diamond better for enamel (also for dentin, but need to acid etch for more time Carbide - cute

Smear Layer after you cut/remove decay you are worign on smear layer in dentin want to expose dentin tubules and leave good dentin to place good bonding material

and add good composite leave dentin damp when placing bonding agent

o If completely dry and dehydrated, bonding wont work b/c dentin will try and get wet.. so leave it damp for retention

o bonding agents are hydrophilic

Conditioner and Acid Etch 1. Redford 1986

o 10% phosphoric acid 15 seconds (primary dentition – 7-10 sec)Primer (methacrylate)

Dehydrating agentso Aldehydeo Acetoneo Alcohol

Bonding agents – pg 25 Technique sensitive

Restorative materials “esthetic color” Silicate cements GI cements Compomers RMGI Composites (resin // “strip crowns”) SSC – modified Zirconia crowns

Pg 27Compomer

Dyract (L.D. Caulk/Dentsply) Compoglass Vivadent/Ivoclar Hytac ESPE

Filler Resins Flowable Composites – less filler

Eliminate Myths//DOGMAS…Restorative materials

Amalgamo Approved for primary dentition (2 surface class II, Class I & V) and

permanent (class I, II, V)o Predictions: Mean survival time

Amalgam vs Composite Recall appts every 6 months for 5 years 267 (6-10 years) amalgam vs compomers in primary teeth

o 6% compomers replaced (recurrent caries)o 0.5% amalgams were replaced (recurrent caries)o statistical significance

267 (6-10 years) amalgams vs composites permanent teetho 12% composites replaced (recurrent caries)o 11% amalgams replaced (recurrent caires)o no statistical significance

composites

o as good as amalgamo wear 50 microns a yearo wear 250 microns over 5 yearso halogen light-silorane decrease shrinkage to 1%

Amalgams vs Health Dalen, 2003 – no correlation detected b/w memory and exposure to amalgam Hujoel, 2005 – no evidence that amalgam placed during pregnancy increased low-

birth-weight risk Bellinger, 2007 – no evidence that amalgam produced adverse neuropsychological

effects over 5 years Lauterbach, 2008 – amalgam did not affect neurological status of children Roberts, 2008 – no change in resistance to mercury or antibiotics in children with or

without amalgam fillings

Pulp TherapyPulp Facts

Anatomical Differences o Primary pulps largero Primary root canals are smallero Primary molar roots have more variable anatomy o Primary teeth predisposed to internal resorption

Optionso Pulp therapy for the primary dentition includes a variety of options, depending

on the vitality of the pulpo Difficult if not impossible to determine clinicallyt the histology of the pukpo We attempt to do this by using clinical & rx info

Pulp Therapy in Primary and young Perm Teeth Pain assessment

Further Clinical Assessment

Extent of lesion location, color Mobility rule out root resorption Soft tissue swelling Lymphadenopathy Sensitivity to percussion reliable in primary teeth Pulp exposure hemorrhagic vs necrotic Pulp testing electrical, thermal, percussion Redness, selling, gross caries, missing/fractured restoration, carious marginal

breakdown, draining parulis, fluctuation felt by palpation, mobility, thermal and electrical vitality tests

Reliability of Pulp Testing No Single Diagnostic Test is Reliable Teeth Primary Young Permanent Mature PermanentElectrical - + +Thermal + + ++Percussion ++ + +

Radiographic Criteria for Healthy Pulp Adequate periodontal support No decalcified lesions or root fractures No internal/external resorption or radiolucency

Radiographic Assessment Accessory canals, no vital pulp tissue w/interradicular bone loss 77.5% mandibular primary molars had accessory canals in floor of chamber

Operative Diagnosis Direct evaluation pulp tissue Nature of the bleeding Red color & hemostasis in less than 4 minutes indicates radicular vitality Persistant bleeding indicates infections has reached radicular pulp

Vital Pulp Therapy Protective base/liner Indirect pulp treatment (IPT) Direct pulp capping (DPC) Pulpotomy

o Pharmacotherapeutico Non-pharmacotherapeutic

Partial pulpotomy (permanent teeth)Protective base/liner

Indications (AAPD):o Normal pulpo Preparation in dentino All caries removed

Objectiveso Preserve pulpal vitalityo Minimize microleakage/sensitivity

Indirect Pulp Treatment (IPT) Indications

o Deep carious lesionso Reversible pulpitiso Incomplete caries removalo No pulp exposureo Pulp vital

Objectives

o Complete seal, preserve vitality, no post-treatment symptoms, no harm to succedaneous teeth, continued root development in permanent teeth

IPT (indirect pulp treatment) Technique Apply medicament/material over carious or sound dentin [Ca(OH)2 most commonly

used] Vitality should be preserved If planning to re-enter, wait 6-8 weeks for tertiary dentin; removed remaining caries,

restore; eliminate microleakage Need to re-enter controversial Radiolucency beneath IPT decreased in size or did not increase under Dycal/ZOE in

majority of cases Success rate up to 90% Recent Data:

o IPT (GIC) had higher success rate than FMC pulpotomies o IPT (Ca[OH]2) success rate in primary molars was 95% in retrospective studyo Carious dentin undergoes mineral gain when sealed in IPT

Deep Caries Thin dentin over pulp Tubules are large in diameter and packed close together Dentin is extremely permeable

Caulk Dycal, Reinforced CaOHVital Pulp Therapy

Protective base/liner Indirect pulp treatment (IPT) Direct pulp capping (DPC) Pulpotomy

o Pharmacotherapeutico Non-pharmacotherapeutic

Partial pulpotomy (permanent teeth)

Direct Pulp Cap Indications

o Small mechanical or traumatic exposure in primary teeth with normal pulpo Small carious or mechanical exposure in permanent teeth with normal pulpo Contraindicated for carious exposure in primary teeth

Objectives:o Preserve vitalityo No post-tx signssymptomso Pulp healingo Tertiary dentino No pathologic changeso No harm to successorso Continued root formation for perm teeth

Pulp Capping Agents Mineral trioxide aggregate (MTA) Ca(OH)2 still widely used and taight ZOE – chronic inflammation Total etch technique

Direct Pulp Cap – Bleeding Success inversely related to bleeding at site Debris @ exposure site: clean out with saline or anesthetic to prevent inflammation;

keep pulp moist Clot will prevent contact of material with the pup Success rate up to 80-90% when bleeding is well controlled

Direct Pulp Capping Even in these cases success rates are not particularly high Failure results in internal resorption or acute dentoalveolar abscess Direct pulp cap success rate on primary teeth is not as great as pulpotomy

Partial Pulpotomy – Criteria No pain or recent pain of short duration No swelling, mobility, reaction to percussion No internal/external resorption, changes in PDL, radiographic abnormalities Pulp exposure 1-2 mm, bleeding stops <1-2 min Inflammation, infection superficial only Only superficial pulp removed

Partial Pulpotomy Technique

Enlarge exposure, removing exposed pulp tissue Place capping materal Place leak-proof seal

o ZOE covered with GIC or calcium hydroxide of resin composite is to be used OBJECTIVES

o Remaining pulp stays vitalo No adverse clinical signs/symptomso Continued apexogenesis in immature teeth

Advantageso Removes inflamed, infected portion of pulpo Preserves cell-rich coronal pulpo Facilitates washing away carious debriso Allows better contact with more materialo Increases healing potentialo Physiological apposition of cervical dentino No need for root canal therapyo Natural color/translucency preserved

Pulpotomy for Primary Teeth Indications:

o Deep lesion adjacent to pulp that is normal or reversibly inflamed, oro Pulp exposed by traumao Coronal tissue can be amputatedo Remaining radicular tissue vital (clinically and radiographically)

Objectiveso Preserve vitality of radicular pulpo No adverse signs or symptomso No radiographic pathology o No harm to succedaneous teeth

Techniqueo Prepare tooth for restoration (typically SSC)o Excavate carious dentin, unroof pulp chambero Amputate coronal pulpo Hemostasis (diagnostic value)o Treat remaining pulp (medicament/energy)o Seal and restore

Clinical indications

o Mechanical/carious exposure, traumao Inflammation limited to coronal pulpo Absence of spontaneous paino Absence of swelling or alveolar abscess formationo Restorable tooth

Contraindicationso Presence of fistula or swellingo Evidence of necrotic pulpo Uncontrolled pulpal hemorrhageo Periapical or bifurcation radiolucencyo Pathologic resorptiono Dystrophic calcificationo More than 1/3 root resorption

Categories of Medicamentso Fixatives

FMC, gluteraldehydeo Mineralizing and/or bacteriostatic agents Ca(OH)2o Palliative sealers

ZOEo Obturators

Mineral trioxide aggregate (MTA)o Coagulants

Iodoform, Ca(OH)2o Antibiotics/Antimicrobials

Erythromycin, othersPulpotomy

The radicular pulp is healthy or is capable of healing after surgical amputation od the affected or infected coronal pulp

Presence of any signs or symptoms of inflammation extending beyond the coronal pulp is a contraindication

Contraindications:o Swelling of pulpal origino Fistulao Pathologic mobilityo Pathologic external root resorptiono Internal root resorption

o Periapical or interradicular radioleucencyo Pulp calcificationso Excessive bleeding from amputated radicular stumpso Hx of spontaneous or nocturnal paino Pain or tenderness to percussion or palpitation

Formocresol Pulpotomy Technique LA and rubber dam Remove superficial caries Remove roof of the pulp chamber Amputate the coronal pulp

o Sharp spoon excavatoro #4 round bur in slow speedo beware of perforating pulpal flooro don’t leave tags of tissue under ledges of dentin

Place moist cotton pellets to obtain hemostasis (apply pressure)o Upon removal pellet, hemostasis should be apparent, minor bleeding may be

evident Formocresol blotted pellet = Buckley’s solution – 1/5 dilution

Following hemostasis place formocresol pellet for 5 mino When removed, site will appear dark brown or dark red

Remove pellet and cover floor of chamber with ZOE Caulk 2200o Lightly condense

Fill access with alloy if temporizing or place SSC same appointment Most authorities now agree that formocresol is at least potentially immunogenic and

mutagenic. For these reasons, efforts have increased to find a substitute medicament.Potential Substitutes for Formocresol

ZOE Glutaraldehyde (GA) Ferric Sulfate SODIUM HYPOCHLORIDE Electocautery Laser No long-term controlled clinical studies are available to elevate their success

Ferric Sulfate Hemostatic agent Clinical studies promising

Fuks et al reported 93% success rate vs. 84% success rate for formocresol at 36 months

Studies on formocresol pulpotomy of primary teeth and the occurance of enamel defects on the permanent successor have found no effect

Pulppotomy Failure Increased mobility, fistulous tract Premature exfoliation Rx evidence of interradicular/periapical radiolucency Internal/external resorption Caused by poor diagnosis and tx selection

Radical Treatment (Non-Vital)Pulpectomy and Root Filling

Indicated on teeth that show evidence of chronic inflammation or necrosis in the radicular pulp

Ideal Indicationo Is a case of pulp destruction of a primary second molar that occurs before the

eruption of the permanent first molar, thus avoiding a distal shoe space maintainer

Pulpectomy Contraindicationso Tooth not restorableo Advanced internal or external resorptiono Less than 2/3 of the primary root structure remainingo Periapical infection involving the crypt of the succedaneous tooth

Root Canal Filling Materialso ZOEo Iodoform Paste (KRI)o Calcium Hydroxide (Vitapex)o Must be resorbable

Pulpectomy Technique Access similar to pulpotomy, but walls flared more Located canal orifice of the roots Use broach to remove as much organic material as possible Endo files are selected and adjusted to stop 2 mm short of rx apex of each canal

Use files w/ sodium hypochlorite irrigation to remove as much organic as possible Dry canals with paper points Fill canals using thin mixture of ZOE (w/o accelerators) using plunger technique or

pressure syringe

STAINLESS STEEL CROWNSRandall, 2000

% failure SSC: 1.9% - 30.3% % failures amalgams: 11.6% - 88.7% AMALGAM:SSC FAILURE RATE 9:1

Ines, 2007 COCHRANE None of the studies accomplished the inclusion criteria That doesn’t mean that SSC are not effective, although we need more info

Messer and Levering, 1988 General Success 88%; less success on teeth tx with pulpotomies

MTA vs Ca(OH)2 Apexification El Meligy and Avery 2006 Necrotic permanent teeth requiring root-end closure

o 15 received MTAo 15 received Ca(OH)2

Recalled at 3, 6, and 12 months 2 Ca(OH)2 failures at 6 and 12 months

o persistent periradicular inflammation NO MTA failure

Pulpal Revascularization of Immature Necrotic Permanent Teeth Assumption:

o Apical portion of pulp may still be vital Goal: encourage vital tissue to migrate coronally Procedure:

o Disinfect root canalo Place triple antibiotic paste (ciprofloxacin, metronidazole, cefaclor)o Remove paste after several weekso Induce bleeding by stimulating tissue beyond apexo Allow clot to reach CEJo Cover with MTA, restore

Resulting clot acts as scaffold to aid growth of new tissue in canal Expect continued root lengthening and thickening, pulp responsive to cold stimulus

RADIOGRAPHSShould I take X-Rays?

Timing of initial rx exam should not be based on age, but upon each child’s individual circumstances

Rx should be taken only when there is an expectation that the diagnostic yield will affect patient care

Sealants

Heller 1995 (5 years) Sound (NO CARIES)

o NO SEALANT – 13% carieso YES SEALANT – 8% caries

Incipient Caries or in doubto NO SEALANT – 52% carieso YES SEALANT – 11% caries

Sealants:1. Autocure, photocure (resins with or w/o filler)2. Change of color3. Autoetch/acid eitch/air abrasion4. Fluoride delivery

Sealants: Fissurotmy – enameloplasty with high (preferred due to microfractures from slow

speed)/low speed with diamond/carbideo High speed vs slow speedo Diamond vs carbide

Laser – can do more conservative tx Air abrasion

Sealant procedure:1. Prophy2. Roughen surface with pumice (w/o fluoride)3. Rinse, etch 15, rinse4. Dry, bond, cure 15 sec5. Sealants, cure

Sealants: If done correctly, can last a very long time, do not have to use a rubber dam, can use cotton roll

Dental Materials – acid etch

1. Redford 1986i. 10% AF

10% PHOSPHORIC ACID 15 secs

Deferred Treatment risks/benefits mist be explained ART/Interim Therapeutic Restoration and regimented application of fluoride varnish

Advanced Behavior Guidance Protective stabilization Sedation General anesthesia

Basic Behavior Guidance Communicative

o Distractiono Tell-show-doo Nonverbalo Positive reinforcemento Voice control

parental presence/absence nitrous oxide - considered as a basic behavior guidance, when anxiolytic/analgesic

levels are usedNitrous Oxide

Inhalational Mechanism: gas is absorbed rapidly (2-3) minutes

o From alveolir and is held in solution in the serum for distribution into tissues and cells of CNS

Effects: Anxiolysis/Analgesiao Anxiolytic effect

Activation of the GABAA receptor through the benzodiazepine binding site

o Analgesic effect Initiated by neuron release of endogenour opiod peptides Activation of poiod receptors, GABAA, noradrenergic pathways

o Mild CNS depressiono Maintenance of blood pressure

Only minor depression of cardiac output w/slight increase on peripheral resistance

Pre-procedural Considerations NOEquipment

Appropriately fitting nasal hood Must be capable of delivering 100% and never less than 30% O2 – fail/safe

mechanism Does not allow nitrous to flow w/o O2 Fail-safe mechanism checked and calibrated regularly (document calibration) Must have scavenging system Emergency cart Positive pressure O2 delivery system

o E cylinder, capable of delivering 90% O2 at 10L/min for 60 minuteso Self-inflating bag-valve-mask device which delivers 15L/min

Personnell and training Must be administered by licensed individuals Personnel must have appropriate training and certification in CPR

Periodic reviews of office emergency protocolAdministration of NO

Must be administered by licensed individuals Flow Rate of 5-6 L/min 100% O2 for 1st 1-2 min titrate nitrous oxide to max 50% continue with communicative techniques, pt become highly suggestible can titrate dose down at subsequent visits, large placebo effect nausea increased by

o longer administration NOo Higher conc NO

If child appears restlesso May be ready to vomito May be entering deeper level of sedation

Use lowest level of NO that produces desired response Clinical observation of pt b4, during, assessed by spoken responses to commands If other pharmacologic agent is used (other than LA) use monitoring consistent with

that required for appropriate level of sedation Use NO > 60% may cause moderate to deep sedation 100% O2 for 3-5 min after discontinuing nitrous document

o percent NO usedo duration procedureo post-tx oxygenationo pt response to NO

Nitrous advantages Rapid onset and recovery time Ease of titration – especially in a calm pt Lack of serious side effects – excellent safely record Can be used with communicative behavior guidance techniques

o Dentist’s behavior major influenceo Communicative techniques more effective with nitrous oxide

Nitrous Disadvantages Weak agent Depends on patient acceptance Patient must be able to breath through nose Occupational hazards

o May increase risk of miscarriage greater in dental personnel with prolonged exposure AND no scavenging system

o May potentiate effects of other sedatives to a dangerous degreeo In high doses may cause nausea or excitement

1-10% patientso diffusion hypoxia may occur if insufficient oxygenation at end of procedure;

rapid release of NO from blood stream into alveoli, diluting concentration of oxygen

headache, disorientationNitrous Oxide Inidcations

Mild to moderate fear Certain mentally, physically, medically compromised patients Patietns with exaggerated gag reflex Cooperatiec patient undergoing a lengthy dental procedure

Pt with difficult achieving local anesthesia Contraindications

COPDCaution – medical consult indicated

Acute ostitis media Severe asthma Sickle cell disease – has been shown to cause neuropathy Bleomycin sulfate therapy (anti-neoplastic antibiotic) – oxygen administration can

lead to interstitial pneumonitis which can be fatalNitrous oxide used with other pharmacologic agents

Increases sedative effect – deepens level of sedationo Chloral hydrate – also increases respiratory depression effecto Diazepamo Midazolam

Advanced Behavior Guidance Documentation Type of stabilization used and why Length of time stabilization used for patient Effectiveness stabilization

Levels of sedation Pt can move from one level to another w/o warning Defined by pt responsiveness and physiologic changes Monitoring requirements increase as level of sedation increases

Monitoring Clinical level of consciousness

Responsiveness Conversation Body movement Eyes open or closed

Monitors during sedation Observation of patient Pulse oximeter Capnograph Pre-cordial stethoscope BP EKG Temp

Considerations for Sedation Familiarity with current guildlines for sedation: State Boards of Medicine and

Dentistry are the ultimate determinants Careful patient selection Choose type of drug based on type/legth of procedure Select lowest does of drug with highest therapeutic index for the procedure Knowledge about drugs being used

o Time of onseto Peak response timeo Duration of action

Informed consent Pre-op instructions, including diet

o Clear liquids – up 2p 2 hrs pre-op

o Breast milk – 4o Infant formula – 6o Non-human milk – 6o Light solid food – 6

Responsible person must be available for transport of pt – preferably 2 individulas Monitoring appropriate to level of sedation, based on guildines Emergency preparednedd, including EMS back up Documentation – pre-op, during, and post-op

Sedation – Patient Selection ASA I & II – generally appropriate for sedation ASA III & IV, special needs, airway abnormalities, increased tonsil size – get

consults as indicated; sedation may be contraindicated in these patients. Consider for possible GA where airway, medical condition can be best monitored

Pt assessmento Med hx – birth to present

Any current illness Chronic conditions

o Physical assessment Cardiovascular Respiratory: airway development and health

Wheezing is common in kids 0-3 yrs Wheezing related to hx of resp syncytial virus (RSV) in

infancy 30% pt with RSV hx in infancy have recurrent lower respiratory

infections or wheezing 6-8 yrs after initial infection

Sedation – tonsil size Brodsky Scale 0 to +4 0 means tonsil is in the fossa +1 means less than 25% obstruction +2 less than 50% +3 less than 75% +4 is more than 75% obstruction

Patient selection – sedation Mallampati classification – size of airway

o Class I – visualization of soft palate, fauces, uvula, anterior and posterior o Class II – visualization of soft palate, fauces and uvula o Class III – visualization of soft palate and base of uvulao Class IV – soft palate not visible

Snoring Gag reflex Current medication, including herbal

o Some medications can increase duration of action of sedative medicationso Behavior assessment

Poor candidate for sedation: Sleep apnea Obesity – greater risk for aspiration, especially with BMI of 85th percent of higher Increased neck circumference – associated with adverse respiratory events Abnormal airway – tongue, tonsils In sedated children with large tonsils, head rolling forward causes significant airway

obstruction Chronic conditions

o Moderate to sever asthma

o Liver or renal diseaseo Poorly controlled seizureso Patients at risk for aspiration: CP, GERD

Sedation: Child’s airway is challenging Diferent anatomy increases risk of airway problems

o Narrow trachea, narrow glottis, narrow nasal passages Relatively larger tongue/epiglottis Mandible less developed Increased airway resistance Monitoring airway

o Head airwayo Snoringo Patient coloro Chest movemento Use rubber dam to protect

Sedation-Respiratory System Ventilation: air movement into/out of lungs

o Higher respiratory rate in childreno Smaller tidal volume in children

Oxygenation: oxygen delivered to tissue (brain)o Requires patient airwayo Transport across alveolio Hb transport of O2o Transport via cardiovascular system

o Metabolic tissue exchange: oxygen-carbon dioxideo Elimination of carbon dioxide

Cardiovascular System Heart rate

o Normal: 4 yr old – 100 beats/mino Normal: 10 yrs – 90 beats/min

Child’s blood pressure totally dependent on heart rate Drop in bl pressure totally dependent on heart rate Drop in heart rate leads to hypotension Hypotension in a child signifies decreased heart rate and should be taken very

seriously Monitoring cardiovascular events

o Blood pressure Cuff should be 2/3 upper arm length Too small – high reading; too large – low reading

o Pulse oximetero Pulse palpitation – closest to heart is best

Routes of administration – general considerationsOral

Most common route Easily accepted – no injections Prolonged onset and recovery Relatively safe if using one drug Using combinations of drugs increases risks of adverse outcomes – less predictable First past hepatic metabolism leads to low bioavailability

Inability to titrateIntranasal

Rapid onseto Nasal mucosa links to CNSo Plasma levels similar to IV

Use atomizer: 1cc syringeo ½ dose to titrate

inability to titrate use lower dose – no first-pass metabolism indicated for patient who refuses oral meds patients find administration unpleasant

Intramuscular Faster absorption than oral Ease of administration – no taste issues Potential for trauma to injection site Prolongued onset and recovery Inability to titrate Painful Increased liability costs

Intravenous Optimum route Rapid onset Drug can be titrated to achieve desired effect Absorption not a factor

Drug can be administered in small amounts over time IV access is available in case of ermegency Difficulty in starting IV in difficult/obese pateints Venipuncture complications – hematoma Requires highest level of monitoring Increases liability costs

Why nitrous oxide Fear of an unpleasant experience, namely pain NO relieves both the physiological and psychological aspects of pain 65% gen dentists and almost 90% ped dentists use NO

Rationale Use of inhalations sedation with NO and O has many significant advantages over

methods of pharmacosedation Low lipid solubility – excellent ability to titrate

Nitrous Advantages:1. Onset of action – onset is more rapid than oral, recatal and IM. IV sedation is roughly equal

2. peak clinical effect – peak clinical actions do not develop for most oral, rectal and IM drugs for a period of time that makes tritation absolutely impossible

3. Alteration of Depth of Sedation depth of sedation achieved with inhalation sedation may be altered from moment to

moment with no other sedation technique does the administrator have as much control over the

clinical action of a drug degree of control represents a significantly safelty feature of inhalation sedation

4. Duration of Action duration of action is an important consideration selection of sedation techniques

5. Recovery Time recovery time from inhalation sedation is rapid and is the most complete of any

technique N2O is not metabolized by the body, the gas is rapidly and virtually completely

eliminated from the body, w/in 3-5 minutes. In all other techniques the recovery form sedation is considerably slower

6. Ability to Titrate titration is ability to administer small incremental doses of a drug until desired

clinical action is obtained. Ability to titrate represents the greatest safety feature a technique can possess

significant drug overdose will not develop in techniques in which titration is possible, as long as the practitioner titrates the drugs used

intravenous and inhalation sedation allow for titration. No other sedation technique is capable of titration

7. Ability to Titrate in the outpatient setting it is in everyone’s best interest that the pt is discharged from

the office with no prohibitions on their activities. Drug administed for the reduction of fear and anxiety are CNS depressants. A patient

must have an escort for a number of hours following administration of these drugs Inhalation sedation recovery is almost always complete, a patient usualyy may be

discharged from the office alone, w/no restrictions 8. safe, very few side effects

9. N2O-O2 has no adverse effects on liver, kidneys, brain, or cardiovascular and respiratory system

11/9 – Space Management Know eruption pattern for primary & permanent dentition Overjet perm: 2mm Overjet primary: 0-4mm Overbite for perm & primary: 2mm Growth of mandible: upward, posterior, backward Gain 1mm on max & 2mm on mand (IDK what this means) Consider bruxism, airway, tongue habits

o Most important: tongue pushes outward & lips & cheek push inward As soon as mand incisors erupt, if no space crowding; if space corrected w/

tongue pressure Intermolar width (b/t primary & perm) the same Canine width will change b/c eruption of teeth facially Bone is added in the back and resorbed in front Maxilla stops growing @ 6 y/o Mandible stops 14-16 +/- 4, boys up to 22

o can wait up to 22 to take out 3rd molarsMaxilla

Grows faster for shorter pd time Anterior and 2° palate 12-13 y/o 1 bone Post cross-bite b/t 6 &9 expansion

Mandible fuses at one y/o grows slower for longer pd of time

Predicted Width Sum incisors/2 + 10.5 = predicted width mand Sum incisors/2 + 11 = predicted width maxillar

Band & Loop – ext first primary molar

If molar already erupted, don’t have to do anything If not in occlusion, band & loop Can’t do lingual lower holding arch if don’t have 4 perm incisors

Band & loop – if need to ext second primary molar Don’t have to place B&L if 2nd permanent molar erupted DO if 2nd permanent molar not erupted

November 16 – Space management (contin) & oral habits Distal shoe: Prevent “mesialization” of 1st permament molar when extraction of 2nd

primary molar is needed When there is space, mandibular molars will “mesialize.” Maxillary molars rotate

Band & Loop Shorter on the buccal, longer on the lingual segment Want canine to be able to “grow in” Don’t want to block premolar from eruptiong

TPA – stop rotation of maxillary 1st molars to prevent space loss

Bands should be 1mm below marginal ridge should not be uncomfortable to gingiva if see ischemia, trim band

Oral habits: as soon as detect, try to remove the habit

try to induce pacifier, rather than finger harder and more harmful remove habit before 3 y/o; after 3, can’t be corrected by removal duration > magnitude > frequency ACTIVE > passive Tongue should be on cingulum of anterior teeth when we swallow >36-48 mo – altered occlusion

o Thumb- ant openbite & increased overjeto Pacifier: post crossbiteo Mouth breathers: ant openbite & post crossbite; send to ENT if airway issueso May need to defer tx if too youngo Gloves, bluegrass appliance, crib, rake: 3-6 y/oo Biting Lip habit: upper incisors flared out, lower inclined linguallyo Pull check in/sucking: ulcer on cheeko V-shaped arch/deep palate: thumb-suckingo Guidance, interception (appliance ASAP), active tx

Treatment: Simple: single tooth Compound: multiple teeth Complex: skeletal discrepancy Compound & complex: dental & skeletal – may need to refer

10/21/15 11:33 AM