3 - Clinical Practice Guidelines - Part 1

Question 1

What is the recommended time for the first clinical oral exam?

Answer 1

The first examination is recommended at the time of the eruption of the first tooth and no later than 12 months of age.

Question 2

What are the components of a comprehensive oral exam?

Answer 2

1. General health/growth
2. Pain
3. Extraoral soft tissue
4. TMJ
5. Intraoral soft tissue
6. Oral hygiene and periodontal health
7. Intraoral hard tissue
8. Developing occlusion
9. Caries risk
10. Behavior of child

Question 3

What is the recall interval?

Answer 3

The most common interval of examination is six months; however, some pts may require examination and preventive services at more or less frequent intervals, based upon historical, clinical and radiographic findings.
–Children at moderate caries risk should receive a professional fluoride treatment at least every six months; those with high caries risk should receive greater frequency of professional fluoride applications (e.g., every 3-6 months).

Question 4

What is the goal of a caries-risk assessment?

Answer 4

The goal is to prevent disease by identifying and minimizing causative factors (e.g., microbial burden, dietary habits, plaque accumulation) and optimizing protective factors (e.g., fluoride exposure, oral hygiene sealants).

Question 5

Why is adolescence a time of heightened caries activity?

Answer 5

1. Increased intake of cariogenic substances

2. Inattention to oral hygiene procedures

Question 6

What type of periodontitis is more common in children and adolescents than adults?

Answer 6

Aggressive periodontitis is more common in children and adolescents than adults.

Question 7

How does caries risk change during the active dental eruption phase?

Answer 7

Newly erupted teeth may be at higher risk of developing caries, especially during the post-eruption maturation process.

Question 8

What is anticipatory guidance?

Answer 8

The process of providing practical, developmentally-appropriate information about children’s health to prepare parents for the significant physical, emotional and psychological milestones.

• -Topics to be included are:
• —-1. Oral hygiene and dietary habits
• —-2. Injury prevention
• —-3. Nonnutritive habits
• —-4. Substance abuse
• —-5. Intraoral/perioral piercing
• —-6. Speech/language development

Question 9

What injury prevention counseling topics should be discussed in the anticipatory guidance?

Answer 9

1. Initially, discussions would include advice regarding play objects, pacifiers, car seats and electrical cords.
2. As motor coordination develops, additional safety and preventive measures, including use of athletic mouthguards for sporting activities.

Question 10

At what age is the greatest incidence of trauma to the primary dentition?

Answer 10

At 2-3 years of age, a time of increased mobility and developing coordination.

Question 11

What are the most common injuries to permanent teeth?

Answer 11

Falls > traffic accidents > violence > sports

Question 12

When should children stop sucking habits?

Answer 12

By 3 years or younger.

• -Although early use of pacifier and digit sucking are considered normal, habits of sufficient frequency, intensity and duration can contribute to deleterious changes in occlusion and facial development.
• -It is important to discuss the need for early pacifier and digit sucking and the need to wean from the habits before malocclusion or skeletal dysplasias occur.

Question 13

When should the initial radiographic exam begin?

Answer 13

Timing of initial radiographic examination should not be based on the pt’s age. Rather, after review of an individual’s history and clinical findings, judicious determination of radiographic needs and examination can optimize pt care while minimizing radiation exposure.

Question 14

Use of an appliance for a malocclusion should only be used if what is true?

Answer 14

Use of an appliance is indicated only when the child wants to stop the habit and would benefit from a reminder.

Question 15

When should a decision to remove or retain third molars be made?

Answer 15

A decision to remove or retain third molars should be made before the middle of the third decade.
–Postoperative complications for removal of impacted third molars are low when performed at an early age.

Question 16

Do impacted third molars affect lower incisor crowding?

Answer 16

No. There is no difference in late lower incisor crowding with removal or retention of asymptomatic impacted third molars.

Question 17

At what age should a patient be referred to a general dentist for continuing oral care.

Answer 17

For patients 12 years and older, at an age determined by patient, parent and pediatric dentist, refer the patient to a general dentist for continuing oral care.

Question 18

Above what age is counseling for speech/language development no longer necessary?

Answer 18

After 6 years old.

Question 19

What is the best predictor of future cares?

Answer 19

Although the best tool to predict future caries is past caries experience, it is not particularly useful in young children due to the importance of determining caries risk before the disease is manifest.

Question 20

What is the modern age relationship between sugar and caries?

Answer 20

While there is no question that fermentable carbohydrates are a necessary link in the causal chain for dental caries, a systematic study of sugar consumption and caries risk has concluded that the relationship between sugar consumption and caries is much weaker in the modern age of fluoride exposure than previously thought.

Question 21

What is the relationship between toothbrushing frequency and caries?

Answer 21

There is only a weak relationship between frequency of brushing and decreased dental caries, which is confounded bc it is difficult to distinguish whether the effect is actually a measure of fluoride application or whether it is a result of mechanical removal of plaque.

Question 22

What information has changed the perspective of modern management of caries vs the historical management of caries?

Answer 22

1. Historically, the management of dental caries was based on the notion that it was a progressive disease that eventually destroyed the tooth unless there was surgical/restorative intervention.
2. It is now known that surgical intervention of dental caries alone does not stop the disease process. Additionally, many lesions do not progress, and tooth restorations have a finite longevity.
   - -Modern management should be more conservative: early detection, identify risk for caries progression, “active surveillance” to apply preventive measures and monitor for signs of arrestment or progression.

Question 23

What is the idea of “active surveillance” of carious lesions?

Answer 23

Active surveillance (prevention therapies and close monitoring) of enamel lesions is based on the concept that :

1. Treatment of disease may only be necessary if there is disease progression.
2. Caries progression has diminished over recent decades.
3. The majority of proximal lesions, even in dentin, are not cavitated.

Question 24

What approaches to the assessment and treatment of dental caries are emerging?

Answer 24

1. There are emerging trends to use calcium and phosphate remineralizing solution to reverse dental caries.
2. Other fluoride compounds, such as silver diamine fluoride and stannous fluoride, may be more effective than sodium fluoride for topical applications.
3. There has been interest in antimicrobials to affect the caries rates, but evidence from caries trials is still inconclusive.
4. Some proven methods, such as prescription fluoride drops and tablets, may be removed from this protocol in the future due to attitudes, risks or compliance.

Question 25

For physicians and other non-dental health care providers, what are the factors in the caries risk assessments for 0-3 year olds?

Answer 25

Biological high risk factors:

1. Mother/primary caregiver has active cavities
2. Parent/caregiver has low socioeconomic status
3. Child has >3 between meal sugar-containing snacks or beverages per day
4. Child is put to bed with a bottle containing natural or added sugar
5. Child has special health care needs
6. Child is a recent immigrant

Clinical findings high risk factor:

1. Child has white spot lesions or enamel defects
2. Child has visible cavities or fillings
3. Child has plaque on teeth

Protective factors:

1. Child receives optimally-fluoridated drinking water or fluoride supplements
2. Child has teeth brushed daily with fluoridated toothpaste
3. Child receives topical fluoride from health professional
4. Child has dental home/regular dental care

Question 26

What are the factors in the caries risk assessment for a dentist evaluating 0-5 year olds?

Answer 26

Biologic high risk factors:

1. Mother/primary caregiver has active cavities
2. Parent/caregiver has low socioeconomic status
3. Child has >3 between meal sugar-containing snacks or beverages per day
4. Child is put to bed with a bottle containing natural or added sugar

Biologic medium risk factors:

1. Child has special health care needs
2. Child is a recent immigrant

Clinical findings high risk factors:

1. Child has >1 decayed/missing/filled surfaces
2. Child has active white spot lesions or enamel defects
3. Child has elevated mutans streptococci levels

Clinical findings medium risk factors:
1. Child has plaque on teeth

Protective factors:

1. Child receives optimally-fluoridated drinking water or fluoride supplements
2. Child has teeth brushed daily with fluoridated toothpaste
3. Child receives topical fluoride from health professional
4. Child has dental home/regular dental care

Question 27

What are the factors in the caries risk assessment for a dentist evaluating 6+ year olds?

Answer 27

Biologic high risk factors:

1. Child has low socioeconomic status
2. Child has >3 between meal sugar-containing snacks or beverages per day

Biologic medium risk factors:

1. Child has special health care needs
2. Child is a recent immigrant

Clinical findings high risk factors:

1. Child has ≥1 interproximal lesions
2. Child has active white spot lesions or enamel defects
3. Child has low salivary flow

Clinical findings medium risk factors:

1. Child has defective restorations
2. Child wearing an intraoral appliance

Protective factors:

1. Child receives optimally-fluoridated drinking water
2. Child has teeth brushed daily with fluoridated toothpaste
3. Child receives topical fluoride from health professional
4. Child has dental home/regular dental care
5. Additional home measures (e.g., xylitol, MI paste, antimicrobial)

Question 28

What are some general examples in a caries management protocol?

Answer 28

1. Active surveillance of all incipient lesions. Can chose to not do active surveillance and restore incipient lesions if pt is high risk and parent not engaged for pts 3 and older.
2. Sealants for all pts including low risk pts for pts 3 and older.
3. Recall interval of 3 months for high risk pts only. Recall interval of 6 months for low and moderate risk pts.
4. Start radiographs at 3 and older. If low risk, radiographs every 12-24 months. If moderate risk, take every 6-12 months. If high risk, take every 6 months.
5. No professional topical fluoride for low risk pts, only toothbrushing twice daily is enough. Do professional topical fluoride for moderate and high risk pts. For high risk pts, they can brush with 0.5% fluoride at 3 years and older.

Question 29

What is the perinatal period?

Answer 29

The period around the time of birth - beginning with the completion of the 20th through 28th week of gestation and ending 1 to 4 weeks after birth.

Question 30

What is the relationship between periodontal disease and adverse outcomes in pregnancy?

Answer 30

Periodontal disease is linked to:

1. Preterm deliveries
2. Low birth weight
3. Preeclampsia (a rapidly progressing condition occurring in pregnancy characterized by hypertension and the presence of proteinuria)

Question 31

When and where can MS colonize in an infant?

Answer 31

When:
–MS can first colonize at birth.

Where:

1. Teeth - significant colonization site bc of non-shedding surface for adherence
2. Furrows of the tongue - important ecological niche in harboring the bacteria in predentate infants.

Question 32

What percent of MS in infants is identical to those in the mother?

Answer 32

24-100%

–The higher the levels of maternal salivary MS, the greater the risk of the infant being colonized.

Question 33

What factors contribute to the transmission and resulting colonization of the mother’s salivary MS into the infant?

Answer 33

1. Magnitude of the inoculum
2. Frequency of inoculation
3. Minimum infective dose
4. Maternal salivary levels of MS
5. Mother’s oral hygiene, periodontal disease
6. Snack frequency
7. Socioeconomic status

Question 34

What percent of children also have non-maternal MS (horizontal transmission)?

Answer 34

74%

Question 35

How can periodontal disease cause preterm delivery?

Answer 35

Mothers with severe periodontitis have high levels of prostaglandin in their gingival crevicular fluid and blood. In turn, these increased levels of prostaglandins may be associated with uterine contractions leading to preterm deliveries.

Question 36

How can pregnancy negatively affect oral health behaviors among pregnant women?

Answer 36

Nausea and vomiting may lead to avoidance of toothbrushing, resulting in an increased caries rate.

Question 37

How can pregnant women reduce their caries risk?

Answer 37

1. For a pregnant woman experiencing frequent vomiting, rinsing with a cup of water containing a teaspoon of baking soda and waiting an hour before brushing can help minimize dental erosion.
2. Using a fluoridated toothpaste, chewing sugarless or xylitol-containing gum and eating small amounts of nutritious food throughout the day can help minimize their caries risk.

Question 38

What kind of mouthwash can help promote enamel remineralization?

Answer 38

Using a fluoridated toothpaste and rinsing with an alcohol-free, over-the-counter mouth rinse containing 0.05% sodium fluoride once a day or 0.02% sodium fluoride rinse twice a day have been suggested to help reduce plaque levels and help promote enamel remineralization.

Question 39

When is the safest time to perform dental treatment during pregnancy?

Answer 39

1. In the second trimester, or the 14th through 20th weeks.
   - -The risk of pregnancy loss is lower in the second trimester compared to that in the first trimester, and organogenesis is complete.
2. Even though the second trimester is usually optimal, dental treatment can be accomplished safely at any time in pregnancy.

Question 40

What are the considerations for amalgam and pregnancy?

Answer 40

Amalgam may be considered as a restorative material in pregnant women. There is no evidence that fetal exposure to mercury released from the mother’s existing amalgam restorations causes any adverse effects.
–Since mercury vapor released during removal and placement of an amalgam restoration may be absorbed into the blood stream and cross the placental barrier, the use of rubber dam and high speed evacuation is recommended.

Question 41

What are the considerations for treatment during the third trimester of pregnancy?

Answer 41

Due to patient positioning, comfort is a consideration for treatment during the third trimester. In these cases, elective treatment sometimes is best deferred until after delivery.

Question 42

What kind of dental problems should be treated as soon as possible in pregnant women?

Answer 42

Acute conditions, such as pain and swelling, should be treated as soon as possible.

• -Delay in necessary treatment could result in significant risk to the mother and indirectly to the fetus.
• -The consequences of not treating an active infection during pregnancy out-weigh the possible risks presented by most of the medications required for dental treatment.

Question 43

How can maternal MS reservoirs be suppressed to help delay the colonization process?

Answer 43

Maternal MS reservoirs can be suppressed by:

1. Dietary counseling
2. Reducing the frequency of simple carbohydrate intake
3. Applying topical chlorhexidine and/or fluoride
4. Removing and restoring active caries
5. Chewing xylitol-containing chewing gum.

Question 44

What is the difference in the prevalence of dental caries in children and in older age groups?

Answer 44

In contrast to declining prevalence of dental caries among children in older age groups, the prevalence of caries in poor US children under the age of five is increasing.

Question 45

What are the recommendations for the parent’s oral health for pts who are infants?

Answer 45

1. Oral health education
2. Comprehensive oral exam
3. Professional oral health care
4. Oral hygiene
5. Diet
6. Fluoride
7. Xylitol chewing gum

Question 46

When should an infant receive an oral health risk assessment from his/her primary health care provider or qualified health care professional?

Answer 46

By six months of age - evaluate the pt’s risk of developing oral disease of soft and hard tissues, including caries-risk assessment, education on infant oral health and evaluate and optimize fluoride exposure.

Question 47

When should an infant have a dental home?

Answer 47

By 12 months of age.

Question 48

What anticipatory guidance should be given to the parents of an infant?

Answer 48

Anticipatory guidance during the initial visit for an infant:

1. Dental and oral development
2. Fluoride status
3. Non-nutritive sucking habits
4. Teething
5. Injury prevention
6. Oral hygiene instruction
7. Effects of diet on the dentition

Question 49

What can teething lead to?

Answer 49

1. Intermittent localized discomfort in the area of erupting primary teeth.
2. Irritability
3. Excessive salivation

–However, many children have no apparent difficulties.

Question 50

What is the treatment for teething?

Answer 50

1. Treatment of symptoms include oral analgesics and chilled rings for the child to “gum”.
2. Use of topical anesthetics, including over-the-counter teething gels, to relieve discomfort are discouraged due to potential toxicity of these products in infants.

Question 51

When should toothbrushing begin?

Answer 51

Oral hygiene measures should be implemented no later than the time of eruption of the first primary tooth.

Question 52

Describe the cariogenicity of breast milk?

Answer 52

1. Human breast milk is uniquely superior in providing the best possible nutrition to infants and has not been epidemiologically associated with caries.
2. Frequent night time bottle feeding with milk and ad libitum breast-feeding are associated with, but not consistently implicated in, ECC.
3. Breastfeeding greater than 7 times daily after 12 months of age is associated with increased risk for ECC.

Question 53

Under what fluoride concentration (ppm) of water should children be considered for systemically-administered fluoride?

Answer 53

Systemically-administered fluoride should be considered for all children at caries risk who drink fluoride deficient water (less than 0.6ppm) after determining all other dietary sources of fluoride exposure.

Question 54

What injury prevention topics would you discuss with the parent of an infant?

Answer 54

Initially discussions would include play objects, pacifiers, car seats and electric cords.

Question 55

What is the definition of adolescent?

Answer 55

There is no standard definition of “adolescent.” Adolescents are defined very broadly as youths between the ages of 10 to 18.

Question 56

How do adolescent pts have distinctive needs?

Answer 56

Adolescent pt is recognized as having distinctive needs due to:

1. Potentially high caries rate
2. Increased risk for traumatic injury and periodontal disease
3. A tendency for poor nutritional habits
4. An increased esthetic desire ad awareness
5. Complexity of combined orthodontic and restorative care (e.g., congenitally missing teeth)
6. Dental phobia
7. Potential use of tobacco, alcohol and other drugs
8. Pregnancy
9. Eating disorders
10. Unique social and psychological needs

Question 57

What do you do if the parent is unable to provide adequate details regarding a pt’s medical history?

Answer 57

If the parent is unable to provide adequate details regarding a pt’s medical history, consultation with the medical health care provider may be indicated.
–The practitioner also may need to obtain additional information confidentially from an adolescent pt.

Question 58

What may contribute to an upward slope of caries in adolescence?

Answer 58

1. Immature permanent tooth enamel
2. A total increase in susceptible tooth surfaces
3. Environmental factors such as diet
4. Independence to seek care or avoid it
5. A low priority for oral hygiene
6. Additional social factors

Question 59

What is the most economical and effective caries prevention measure?

Answer 59

Fluoridation of community drinking water has proven to be the most economical and effective caries prevention measure.

Question 60

Systemic fluoride or professionally-prescribed fluoride supplements intake is recommended to what age?

Answer 60

Systemic fluoride intake via optimal fluoridation of drinking water or professionally-prescribed supplements is recommend to 16 years of age.
–Supplements should be given only after all other sources of fluoride have been evaluated.

Question 61

What is the cause of higher prevalence of gingivitis during adolescence?

Answer 61

Adolescents have a higher prevalence of gingivitis than prepubertal children or adults. The rise of sex hormones during adolescence is suspected to be a cause of the increased prevalence.
–The inflammatory gingivitis is believed to be transient as the body accommodates to the ongoing presence of the sex hormones.

Question 62

How do sex hormones affect gingivitis during adolescence?

Answer 62

1. The increase in sex hormones during puberty affects the composition of the subgingival microflora.
2. Circulating sex hormones may alter capillary permeability and increase fluid accumulation in the gingival tissues.

Question 63

What third molar problems merits evaluation for removal?

Answer 63

Impaction or malposition leading to problems such as:

1. Pericoronitis
2. Caries
3. Cysts
4. Periodontal problems

Question 64

When do most adolescent pregnancies occur?

Answer 64

Approximately 50% of adolescent pregnancies occur within the first six months of initial sexual intercourse, even with increasing use of contraceptives by adolescents.

Question 65

What are the medical complication risks in pregnant females?

Answer 65

Medical complications:

1. Delivery of low birth weight infants
2. Increased neonatal death rate
3. Increased mortality rate for the mother
4. Pregnancy-induced hypertension, anemia, sexually transmissible diseases and premature delivery.

Question 66

Why is maternal hypertension significant?

Answer 66

1. Hypertension increases the risk of bleeding during procedures.
2. Blood pressure greater than or equal to 140/90 mmHg is considered mild hypertension. Blood pressure greater than or equal to 160/110 mmHg is considered severe hypertension.

Question 67

What nutrients are important during pregnancy?

Answer 67

1. Folate
2. Vitamin B6
3. Vitamin B12
4. Calcium
5. Zinc

Question 68

What should the caloric intake be during pregnancy?

Answer 68

1. During pregnancy, a woman’s nutritional needs are increased, but certainly the “eating for two” concept is not recommended.
2. The total energy needs during pregnancy range between 2,500 to 2,700 kcal a day for most women, but pre-pregnancy body mass index, rate of weight gain, maternal age and physiological appetite must be considered in tailoring this recommendation to the individual.

Question 69

What percent of pregnant women have nausea and vomiting?

Answer 69

Nausea and vomiting occur in 50-90% of all pregnancies during the first trimester and often are associated with young age and low socioeconomic status.

Question 70

What are the risks to pregnancy for pregnant women who smoke?

Answer 70

1. Increased risk for ectopic pregnancy, spontaneous abortion and preterm delivery.
2. Infants born to women who smoke during pregnancy are more likely to be small for gestational age and have low birth-weight.
   - -The longer the mother smokes during pregnancy, the greater the effect on the infant’s birth weight.
3. Maternal tobacco use is associated with intellectual disability and birth defects such as oral clefts.
4. Risk for perinatal mortality (i.e., stillbirths and neonatal deaths) and sudden infant death syndrome (SIDS) is increased for infants of women who smoke.
5. Infants and children exposed to environmental tobacco smoke (i.e., second hand smoke) have higher rates of lower respiratory illness, middle ear infections, asthma and caries in the primary dentition.

Question 71

What oral conditions are associated with pregnancy?

Answer 71

1. Increase in caries - associated with carbohydrate loading as snacking becomes more frequent.
2. Perimyolysis - an erosion of the lingual surfaces of the teeth caused by exposure to gastric acids. May be contributed by morning sickness and vomiting/reflux.
3. Dry mouth - may be caused from pregnancy-associated hormonal changes.
4. Gingivitis - signs of gingivitis (e.g., bleeding, redness, swelling, tenderness) are evident in the second trimester and peak in the eighth month of pregnancy, with anterior teeth affected more than posterior teeth.
5. Increased tooth mobility - associated with microbial shifts from aerobic to anaerobic bacteria. These bacterial shifts are accompanied by increased inflammation in the attachment apparatus, as well as mineral disturbances in the lamina dura, causing tooth mobility. This condition appears to reverse postpartum.

Question 72

What change in oral bacteria are seen in pregnant women?

Answer 72

The effects of hormonal levels on the gingival status of pregnant women may be accompanied by increased levels of Bacteroides, Prevotella and Porphyromonas.

Question 73

Does periodontal treatment on pregnant women affect pregnancy?

Answer 73

The best available evidence to date shows that periodontal treatment has no effect on birth outcomes of preterm labor and low preterm birth weight and is safe for the mother and fetus.

Question 74

What is the concerns for not receiving oral health care during pregnancy?

Answer 74

Untreated oral disease may compromise the health of the pregnant female and the unborn child. The consequences of not treating an active infection during pregnancy outweigh the possible risks presented by most of the medications required for dental care. In addition, deferring elective dental treatment during a healthy pregnancy is not justified.

Question 75

How much radiation exposure is received from dental x-rays?

Answer 75

The amount of radiation exposure from dental x-rays is very small, ranging from 0.038 millisieverts (mSv) for bitewing radiographs to 0.15 mSv for a full mouth series.

Question 76

How do you reduce radiation exposure to the fetus of a pregnant patient?

Answer 76

1. Optimizing techniques
2. Shielding the thyroid and abdomen
3. Using the fastest available image receptor [i.e., high-speed film (image receptors of speeds slower than ANSI speed group E shall not be used), rare earth screen-film systems, digital radiography]
4. Avoiding retakes

Question 77

What are the concerns of radiation exposure to the thyroid gland?

Answer 77

1. The primary dental x-ray beam may pass near or through the thyroid gland, even with attention to proper radiographic techniques.
2. The juvenile thyroid is among the most sensitive organs to radiation-induced tumors, both benign and malignant. Risk decreases significantly with age at exposure, essentially disappearing after age 20.
3. Evidence shows that radiation exposure to the thyroid during pregnancy is associated with low birthweight.
4. Common dental projections rarely, if ever, deliver a measurable absorbed dose to the embryo or fetus. Gonadal absorbed dose from a typical dental x-ray procedure is equivalent to about one hour of natural background radiation.

Question 78

What is the National Council on Radiation Protection and Measurements’ view on radiation and dental treatment during pregnancy?

Answer 78

The National Council on Radiation Protection and Measurements recommends if dental treatment is to be deferred until after the delivery, so should the dental radiographs.

Question 79

What are the objectives of professional oral health care during the first trimester?

Answer 79

Objectives include avoiding:

1. Fetal hypoxia
2. Premature labor/fetal demise
3. Teratogenic effects

Question 80

What are the considerations for the use of nitrous oxide during pregnancy?

Answer 80

1. Due to the increased risk of pregnancy loss, use of nitrous oxide may be contraindicated in the first trimester of pregnancy.
2. Consultation with the prenatal medical provider should precede use of nitrous oxide/oxygen analgesia/anxiolysis during pregnancy.
3. Nitrous oxide should be limited to cases where topical and local anesthetics alone are inadequate.

Question 81

What dental procedures can be undertaken any time during pregnancy?

Answer 81

1. Prevention, diagnosis and treatment of oral diseases (including needed dental x-rays and use of local anesthesia) are highly beneficial and can be undertaken any time during pregnancy with no additional fetal or maternal risk as compared to not providing care.
2. It is safe to provide dental treatment throughout pregnancy; however, bc the pregnant uterus is below the umbilicus, the woman is generally more comfortable during weeks 14 to 20 of gestation.

Question 82

What risk is there due to pregnant women having a large stomach?

Answer 82

Pregnant women are considered to have a “full stomach” due to delayed gastric emptying and, therefore, are at increased risk for aspiration, particularly during the last trimester.

Question 83

What is the sequence of dental treatments that can be provided to pregnant patients?

Answer 83

1. Ideally, a dental prophylaxis should be performed during the first trimester and again during the third trimester if oral home care is inadequate or periodontal conditions warrant professional care.
2. Elective restorative and periodontal therapies should be performed during the second trimester and may prevent any dental infections or other complications from occurring in the third trimester.
3. In the final trimester, a dental prophylaxis may be repeated, especially if home oral care is inadequate or if soft tissue is abnormal.
4. Dental treatment for a pregnant pt who is experiencing pain or infection should not be delayed until after delivery.

Question 84

What effect does mercury from amalgam have on pregnancy?

Answer 84

1. Evidence is insufficient to support or refute that mercury exposure from dental amalgams contributes to adverse pregnancy outcomes. Currently, there is no evidence that the exposure of a fetus to mercury releases from the mother’s existing amalgam fillings causes any adverse effects.
2. Mercury vapor released during the removal or placement of amalgam restorations may be inhaled and absorbed into the blood stream and does cross the placental barrier.
   - -The use of rubber dam and high speed suction can reduce the risk of vapor inhalation.
3. Bc use of tooth whitening products that contain or generate hydrogen peroxide results in release of inorganic mercury from dental amalgams, these products should be avoided during pregnancy by pts who have amalgam restorations.

Question 85

What rinses can pregnant pts use?

Answer 85

Beginning in the sixth month of pregnancy, a daily rinse of 0.05% sodium fluoride and 0.12% chlorhexidine has resulted in significant reduction in levels of caries-causing bacteria, consequently delaying the colonization of such bacteria among offspring.

Question 86

What are the scenarios for legal consent in pregnant pts?

Answer 86

1. In some states, dentists are required to obtain parental consent for non-emergency dental services provided to a child 17 years of age or younger who remains under parental care.
   - -This would involve obtaining consent from the parent who must be aware of the pregnancy in order to understand the risks and benefits of the proposed dental treatment.
   - -However, if the parent is unaware of the pregnancy, the pregnant adolescent may be entitled to confidentiality regarding health issues such as the pregnancy.
2. In other states, there are “mature minor” laws that allow minors to consent for their own health care when a dentist deems the minor competent to provide informed consent.
3. In addition, some states emancipate minors who are pregnant or by court order.

Question 87

What should counseling for all pregnant patients address?

Answer 87

1. Relationship of maternal oral health with fetal health (e.g., possible association of periodontal disease with preterm birth and pre-eclampsia).
2. An individualized preventive plan including oral hygiene instructions, rinses, and/or xylitol gum to decrease the likelihood of MS transmission post-partum.
3. Dietary considerations (e.g., maintaining a healthy diet, avoiding frequent exposures to cariogenic foods and beverages, overall nutrient and energy needs).
4. Anticipatory guidance for the infant’s oral health including the benefits of early establishment of a dental home.
5. Anticipatory guidance for the adolescent’s oral health to include injury prevention, oral piercings, tobacco and substance abuse, sealants, and third molar assessment.
6. Oral changes that may occur secondary to pregnancy (e.g., xerostomia, shifts in oral flora).
7. Individualized treatment recommendations based upon the specific oral findings for each pt.

Question 88

What is the AAPD’s position on prenatal fluoride supplements to benefit the fetus?

Answer 88

The AAPD does not support the use of prenatal fluoride supplements to benefit the fetus.

Question 89

What can a pregnant adolescent experiencing morning sickness or gastroesophageal reflux do to minimize dental erosion?

Answer 89

1. Rinse with a cup of water containing a teaspoon of sodium bicarbonate and to avoid tooth brushing for about one hour after vomiting to minimize dental erosion caused by stomach acid exposure.
2. Where there is established erosion, fluoride may be used to minimize hard tissue loss and control sensitivity. A daily neutral sodium fluoride mouth rinse or gel to combat enamel softening by acids and control pulpal sensitivity may be prescribed.

Question 90

What drugs should be avoided in pregnant patients?

Answer 90

1. Health care providers should avoid the use of aspirin, aspirin-containing products, erythromycin estolate and tetracycline in the pregnant pt.
2. NSAIDs routinely are not recommended during pregnancy; if necessary, administration should be avoided during the first and third trimesters and be limited to 48 to 72 hours.

Question 91

What is positive youth development?

Answer 91

1. The pediatric dentist should incorporate positive youth development (PYD) into care for the adolescent pt. This approach goes beyond traditional prevention, intervention and treatment of risky behaviors and problems and suggests that a strong interpersonal relationship between the adolescent and the pediatric dentist can be influential in improving adolescent oral health and transitioning to adult care.
2. Through PYD, the dentist can promote healthy lifestyles, teach positive patterns of social interaction and provide a safety net in times of need.

Question 92

What is special health care needs?

Answer 92

The AAPD defines special health care needs as “any physical developmental, mental, sensory, behavioral, cognitive or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs.

Question 93

What does the Americans with Disabilities Act require?

Answer 93

1. The Americans with Disabilities ACT (AwDA) defines the dental office as a place of public accommodation. Thus, dentists are obligated to be familiar with these regulations and ensure compliance.
2. Failure to accommodate patients with special health care needs could be considered discrimination and a violation of federal and/or state law.
3. Requirements require practitioners to provide physical access to an office (e.g., wheelchair ramps, disabled-parking spaces).

Question 94

What are the common barriers for medically necessary oral health care for patients with special health care needs?

Answer 94

1. Financing and reimbursement have been cited as common barriers for medically necessary oral health care.
2. Finding a dental home for non-pediatric SHCN pts could be challenging. Pediatric hospitals, by imposing age restrictions, can create another barrier to care for these pts. This presents difficulties for pediatric dentists providing care to adult SHCN pts who have not yet transitioned to adult primary care.
3. Some pediatric hospitals require dentists to be board certified, thus making it difficult for general dentists to obtain hospital privileges. Outpatient surgery centers may be an alternative, although they may not be the preferred setting to treat medically compromised pts.

Question 95

Can a pediatric dentist continue to provide care for adult specialized health care needs pts?

Answer 95

Yes.

• At a time agreed upon by the pt, parent and pediatric dentist, the pt should be transitioned to a dentist knowledgeable and comfortable with managing the pt’s specific health care needs.
• -In cases where this is not possible or desired, the dental home can remain with the pediatric dentist and appropriate referrals for specialized dental care should be recommended when needed.

Question 96

What do you do if you can’t communicate with a pt with special health care needs?

Answer 96

1. At times a parent, family member or caretaker may need to be present to facilitate communication and/or provide information that the pt cannot.
2. According to the requirements of the Americans with Disabilities ACT (AwDA), if attempts to communicate with a pt with SHCN/parent are unsuccessful bc of a disability such as impaired hearing, the dentist must work with those individuals (parent, family member or caretaker) to establish an effective means of communications.

Question 97

Give examples of an individualized oral hygiene program that takes into account the unique disability of the pt?

Answer 97

1. If a pt’s sensory issues cause the taste or texture of fluoridated toothpaste to be intolerable, a fluoridated mouth rinse may be applied with the toothbrush.
2. Toothbrushes can be modified to enable individuals with physical disabilities to brush their own teeth.
3. Electric toothbrushes and floss holders may improve pt compliance.

Question 98

What can be done to help pts with SHCN who have gingivitis?

Answer 98

In cases of gingivitis and periodontal disease, chlorhexidine mouth rinse may be useful. For pts who might swallow a rinse, a toothbrush can be used to apply the chlorhexidine.

Question 99

What kind of physical abuse can occur in the oral cavity?

Answer 99

1. Oral injuries may be inflicted with instruments such as eating utensils or a bottle during forced feedings, hands, fingers or scalding liquids or caustic substances.
2. The abuse may result in: contusions, burns, or lacerations of the tongue, lips, buccal mucosa, palate (soft and hard), gingivae, alveolar mucosa, or frenum; fractured, displaced, or avulsed teeth; or facial bone and jaw fractures.

Question 100

Where is the most common site for inflicted oral injuries?

Answer 100

In one study, the lips were the most common site for inflicted oral injuries (54%), followed by the oral mucosa, teeth, gingivae and tongue.

Question 101

What injuries may be caused by caregivers with factitious disorder by proxy?

Answer 101

Some serious injuries of the oral cavity, including posterior pharyngeal injuries and retropharyngeal abscesses, may be inflicted by caregivers with factitious disorder by proxy to simulate hemoptysis or other symptoms requiring medical care.

Question 102

What should arouse your suspicion of abuse?

Answer 102

1. Multiple injuries
2. Injuries in different stages of healing
3. A discrepant history

Question 103

What is pathognomonic of sexual abuse?

Answer 103

Oral and perioral gonorrhea in prepubertal children, diagnosed with appropriate culture techniques and confirmatory testing, is pathognomonic of sexual abuse but rare among prepubertal girls evaluated for sexual abuse.

Question 104

How is human papillomavirus transmitted?

Answer 104

1. Sexually transmitted through oral-genital contact.
2. Vertically transmitted from mother to infant during birth.
3. Horizontally transmitted through nonsexual contact from a child or caregiver’s hand to the genitals or mouth.

Question 105

What are signs of forced oral sex?

Answer 105

Unexplained injury or petechiae of the palate, particularly at the junction of the hard and soft palate, may be evidence of forced oral sex.

Question 106

What are the caries-protective mechanisms of action?

Answer 106

Topical

1. Low levels of fluoride in plaque and saliva inhibit the demineralization of sound enamel and enhance the remineralization of demineralized enamel.
2. Fluoride inhibits dental caries by affecting the metabolic activity of cariogenic bacteria.
3. High levels of fluoride, such as those attained with the use of topical gels or varnishes, produce a temporary layer of calcium fluoride-like material on the enamel surface. The fluoride is released when the pH drops in response to acid production and becomes available to remineralize enamel or affect bacterial metabolism.

Question 107

Why is it an oversimplification to designate fluoride simply as “systemic” or “topical”?

Answer 107

1. Fluoride that is swallowed, such as fluoridated water and dietary supplements, may contribute to a topical effect on erupted teeth (before swallowed, as well as a topical effect due to increasing salivary and gingival crevicular fluoride levels).
2. Elevated plasma fluoride levels can treat the outer surface of fully mineralized, but unerupted, teeth topically.

Question 108

Why did the Department of Health and Human Services propose to not have a fluoride range, but rather to limit the recommendation of fluoride?

Answer 108

Since fluoride from water supplies is now one of several sources of fluoride, the Department of Health and Human Services recently has proposed to not have a fluoride range, but rather to limit the recommendation to the lower limit of 0.7ppm F. The rationale is to balance the benefits of preventing dental caries while reducing the chance of fluorosis.

Question 109

What are the most commonly used agents for professionally-applied fluoride treatments?

Answer 109

1. 5% sodium fluoride varnish (NaFV; 22,500 ppm F)

2. 1.23% acidulated phosphate fluoride (APF; 12,300 ppm F)

Question 110

What are the considerations for topical fluoride gel and foam products?

Answer 110

1. Some topical fluoride gel and foam products are marketed with recommended treatment times of less than four minutes, but there are no clinical trials showing efficacy of shorter than four-minute application times.
2. There also is limited evidence that topical fluoride foams are efficacious.

Question 111

What are some commonly used agents for home fluoride treatments?

Answer 111

1. 0.2% sodium fluoride (NaF) mouthrinse (900 ppm F)

2. 1.1% sodium fluoride (NaF) brush-on gels/pastes Na F (5,000 ppm F)

Question 112

What factors during xylitol use may help decrease caries?

Answer 112

The mechanical action of chewing a gum containing xylitol along with subsequent increased volume of saliva may assist with caries reduction.

Question 113

What is the minimum daily dose required for xylitol to have a clinical effect?

Answer 113

1. There is accumulating evidence that total daily doses of 3-8 grams of xylitol are required for a clinical effect.
2. Dosing frequency should be a minimum of 2 times a day, not to exceed 8 g per day.

Question 114

What is the recommendation for xylitol use for children at moderate or high caries risk?

Answer 114

1.

Question 115

What product may be a xylitol delivery vehicle for infants?

Answer 115

A pacifier with a pouch containing slow release xylitol in tablet form, not yet available int he US, has shown high salivary xylitol concentrations and may be a potential delivery vehicle for infants.

Question 116

What kind of xylitol toothpaste is effective?

Answer 116

Studies using toothpaste formulations with 10% xylitol (dose of 0.1g/brushing) have shown reductions in MS levels and caries in children.
–The toothpastes that were studied are not for sale in the US. Furthermore, the xylitol-containing toothpastes that currently are sold in the US have never been tested and their formulas differ from those tested.

Question 117

What is important in identifying pain in younger children?

Answer 117

1. Children under age four are more sensitive to painful stimuli and are not able to communicate as well as older children and teens.
2. Observing behavior and listening to children during treatment are essential in any evaluation of pain. Facial expressions, crying, complaining and body movement are important diagnostic criteria.

Question 118

What are the most validated pain scales to use with children?

Answer 118

1. The Faces Pain Scale-Revised (FPSR) is the most validated for children between ages 4-12.
2. The Wong-Baker FACES Pain Scale is the most validated for children over 3 years of age.

Question 119

What dentist behaviors are correlated with low parent satisfaction?

Answer 119

1. Rushing through appointments
2. Not taking time to explain procedures
3. Barring parents from the examination room
4. Generally being impatient

-Relationship/communication problems have been demonstrated to play a prominent role in initiating malpractice actions. Even where no error occurred, perceived lack of caring and/or collaboration were associated with litigation.

Question 120

What are efficacious responses to uncooperative patient behaviors?

Answer 120

Dentist behaviors of:

1. Vocalizing
2. Directing
3. Empathizing
4. Persuading
5. Giving the pt a feeling of control
6. Operant conditioning

Question 121

How can you educate the parent before the child’s first dental visit?

Answer 121

Discussing the office procedures on the initial telephone call, followed by sending office information and an invitation to visit the office website or even an office “pre-visit”, may be helpful in reducing parental anxiety.

Question 122

How is communication accomplished in the dental setting?

Answer 122

It is affected primarily through:

1. Dialogue
2. Tone of voice
3. Facial expression
4. Body language

Question 123

What are the four essential ingredients of communication?

Answer 123

1. The sender.
2. The message, including the facial expression and body language of the sender.
3. The context or setting in which the message is sent.
4. The receiver.

• For successful communication to take place, all four elements must be present and consistent. Without consistency, there may be a poor “fit” between the intended message and what is understood.
• Communication may be impaired when the sender’s expression and body language are not consistent with the intended message. When body language conveys uncertainty, anxiety or urgency, the dentist cannot effectively communicate confidence in his/her clinical skills.

Question 124

What kind of communication interchange occurs before the procedure and during the procedure?

Answer 124

1. Before the procedure - two-way interchange of information.
2. During the procedure - one-way guidance of behavior through commands (“requests and promises”).

Question 125

How can the dental office be made “child friendly”?

Answer 125

1. The use of themes in its decoration.
2. Age-appropriate toys and games in the reception room or treatment areas.
3. Smaller scale furniture.

Question 126

What influences a child’s reaction to the dental setting?

Answer 126

1. Child age/cognitive level
2. Temperament/personality characteristics
3. Anxiety and fear
4. Reaction to strangers
5. Previous dental experiences
6. Maternal dental anxiety

Question 127

What are the reasons for noncompliance in the healthy, communicating child?

Answer 127

1. Fear transmitted from parents
2. Previous unpleasant and/or painful dental or medical experience
3. Inadequate preparation for the first encounter in the dental environment
4. Dysfunctional parenting practices

Question 128

How can a dentist alleviate barriers to a good behavior outcome?

Answer 128

1. Establish and maintain the “teacher-student” role and relationship.
2. Establish a dental home as early as possible.

Question 129

When does dental treatment necessitate prompt treatment?

Answer 129

1. Rapidly advancing disease
2. Trauma
3. Pain
4. Infection

Question 130

What is essential to obtaining informed consent?

Answer 130

Informing the parent about the nature, risk and benefits of the technique to be used and any professionally-recognized or evidence-based alternative techniques.

Question 131

What behavior guidance technique does not require consent?

Answer 131

1. Communicative management, by virtue of being a basic element of communication, requires no specific consent.
   - -All other behavior guidance techniques require informed consent consistent with the AAPD’s Guideline on Informed Consent and applicable state laws.
2. In the event of an unanticipated reaction to dental treatment, it is incumbent upon the practitioner to protect the pt and staff from harm. Following immediate intervention to assure safety, if techniques must be altered to continue delivery of care, the dentist must have informed consent for the alternative methods.

Question 132

What is tell-show-do and when is it used?

Answer 132

1. Tell - verbal explanations of procedures in phrases appropriate to the developmental level of the pt.
   - -Show - demonstrations for the pt of the visual, auditory, olfactory and tactile aspects of the procedure in a carefully defined, nonthreatening setting.
   - -Do - without deviating from the explanation and demonstration, completion of the procedure.
2. The objectives of tell-show-do are to:
   - -Teach the pt important aspects of the dental visit and familiarize the pt with the dental setting.
   - -Shape the pt’s response to procedures through desensitization and well-described expectations.
3. Indications - may be used with any pt.
   - -Contraindications - none.

Question 133

What is voice control and when is it used?

Answer 133

1. Voice control is a controlled alteration of voice volume, tone or pace to influence and direct the pt’s behavior. Parents unfamiliar with this possibly aversive technique may benefit from an explanation prior to its use to prevent misunderstanding.
2. The objectives of voice control are to:
   - -Gain the pt’s attention and compliance.
   - -Avert negative or avoidance behavior.
   - -Establish appropriate adult-child roles.
3. Indications - may be used with any pt.
   - -Contraindications - pts who are hearing impaired.

Question 134

What is nonverbal communication and when is it used?

Answer 134

1. Nonverbal communication is the reinforcement and guidance of behavior through appropriate contact, posture, facial expression and body language.
2. The objectives of nonverbal communication are to:
   - -Enhance the effectiveness of other communicative management techniques.
   - -Gain or maintain the pt’s attention and compliance.
3. Indications - may be used with any pt.
   - -Contraindications - none.

Question 135

What is positive reinforcement and when is it used?

Answer 135

1. Positive reinforcement is an effective technique to reward desired behaviors and, thus, strengthen the recurrence of those behaviors.
   - -Social reinforcers include positive voice modulation, facial expression, verbal praise and appropriate physical demonstrations of affection by all members of the dental team.
   - -Nonsocial reinforcers include tokens and toys.
2. The objective of positive reinforcement is to reinforce desired behavior.
3. Indications - may be used with any pt.
   - -Contraindications - none.

Question 136

What is distraction and when is it used?

Answer 136

1. Distraction is the technique of diverting the pt’s attention from what may be perceived as an unpleasant procedure. Giving the pt a short break during a stressful procedure can be an effective use of distraction prior to considering more advanced behavior guidance techniques.
2. The objectives of distraction are to:
   - -Decrease the perception of unpleasantness.
   - -Avert negative or avoidance behavior.
3. Indications - may be used with any pt.
   - -Contraindications - none.

Question 137

What is parental presence/absence and when is it used?

Answer 137

1. The presence or absence of the parent sometimes can be used to gain cooperation for treatment.
   - -Parents’ desire to be present during their child’s treatment does not mean they intellectually distrust the dentist. It might mean they are uncomfortable if they visually cannot verify their child’s safety.
   - -It is important to understand the changing emotional needs of parents bc of the growth of a latent but natural sense to be protective of their children. Practitioners should become accustomed to this added involvement of parents and welcome the questions and concerns for their children. Practitioners must consider parents’ desires and wishes and be open to a paradigm shift in their own thinking.
2. The objectives of parental presence/absence are:
   - -For parents to:
   - —-Participate in infant examinations and/or treatment (if asked).
   - —-Offer very young children physical and psychological support.
   - —-Observe the reality of their child’s treatment.
   - -For practitioners to:
   - —-Gain the pt’s attention and improve compliance.
   - —-Avert negative or avoidance behaviors.
   - —-Establish appropriate dentist-child roles
   - —-Enhance effective communication among the dentist, child and parent.
   - —-Minimize anxiety and achieve a positive dental experience
   - —-Facilitate rapid informed consent for changes in treatment or behavior guidance.
3. Indications - may be used with any pt.
   - -Contraindications - parents who are unwilling or unable to extend effective support (when asked).

Question 138

What is nitrous oxide/oxygen inhalation and when is it used?

Answer 138

1. Nitrous oxide/oxygen inhalation is a safe and effective technique to reduce anxiety and enhance effective communication.
   - -Its onset of action is rapid, the effects easily are titrated and reversible and recovery is rapid and complete.
2. Nitrous oxide/oxygen inhalation mediates a variable degree of analgesia, amnesia and gag reflex reduction.

Question 139

What kind of children often require advanced behavior guidance?

Answer 139

1. Children who lack psychological or emotional maturity.

2. Children with mental, physical or medical disability.

Question 140

On average, predoctoral pediatric dentistry programs teach students to treat children of what ages?

Answer 140

On average, predoctoral pediatric dentistry programs teach students to treat children four years of age and older, who are generally well behaved and have low level of caries.

Question 141

What is protective stabilization?

Answer 141

The broad definition of protective stabilization is the restriction of pt’s freedom of movement, with or without the pt’s permission to decrease risk of injury while allowing safe completion of treatment.

• -The restriction may involve another human(s), a pt stabilization device, or a combination thereof.
• -The use of a mouth prop in a compliant child is not considered protective stabilization.

Question 142

What are the risks associated with protective stabilization?

Answer 142

The use of protective stabilization has the potential to produce serious consequences, such as:

1. Physical or psychological harm
   - -Stabilization devices placed around the chest may restrict respirations, they must be used with caution, especially for pts with respiratory compromise (e.g., asthma) and/or who will receive medications (i.e., local anesthetics, sedatives) that can depress respirations.
2. Loss of dignity
   - -Research has demonstrated that psychological trauma can have lasting detrimental effects on brain function and when this trauma is of sufficient intensity, frequency or duration, subsequent neurodevelopment may be altered and become maladaptive.
3. Violation of a pt’s rights

• Careful, continuous monitoring of the pt is mandatory during protective stabilization.
• A rigid stabilization board may not allow for complete extension of the neck and therefore, may compromise airway patency, especially in young children or sedated pts. Proper training and use of a neck roll may minimize this risk.

Question 143

What informed consent considerations should be considered about protective stabilization?

Answer 143

1. Protective stabilization with or without a restrictive device, performed by the dental team requires informed consent from a parent.
   - -Informed consent discussion, when possible should occur on a day separate from the treatment.
   - -Informed consent also should be obtained prior to a parent’s performing protective stabilization during dental procedures.
2. When appropriate, an explanation to the pt regarding the need for restraint, with an opportunity for the pt to respond, should occur.
   - -Although a minor does not have the statutory right to give or refuse consent for treatment, the child’s wishes and feelings (assent) should be considered when addressing the issue of consent.

Question 144

What must be in the pt’s record for use of protective stabilization?

Answer 144

1. Informed consent for stabilization
2. Indication for stabilization
3. Type of stabilization
4. Reason for parental exclusion during protective stabilization (when applicable).
5. The duration of application of stabilization
6. Behavior evaluation/rating during stabilization
7. Any untoward outcomes, such as skin markings
8. Management implications for future appointments

Question 145

What are the objectives for protective stabilization?

Answer 145

The objectives of pt stabilization are to:

1. Reduce or eliminate untoward movement
2. Protect pt, staff, dentist or parent from injury
3. Facilitate delivery of quality dental treatment

Question 146

When should protective stabilization be used?

Answer 146

Indications:

1. Pt requires immediate diagnosis and/or urgent limited treatment and cannot cooperate due to lack of maturity or mental or physical disability.
2. The safety of the pt, staff, dentist or parent would be at risk without the use of protective stabilization.
3. A previously cooperative pt quickly becomes uncooperative during the appointment in order to protect the pt’s safety and help to expedite completion of treatment.
4. Sedated pts require limited stabilization to help reduce untoward movement.
5. A pt with special health care needs may experience uncontrolled movements that would be harmful or significantly interfere with the quality of care.

Contraindications:

1. Cooperative non-sedated pts.
2. Pts who cannot be immobilized safely due to associated medical or physical conditions.
3. Pts who have experienced previous physical or psychological trauma from protective stabilization (unless no other alternatives are available).
4. Non-sedated pts with non-emergent treatment requiring lengthy appointments.

Question 147

What are the precautions regarding protective stabilization?

Answer 147

1. The pt’s medical history must be reviewed carefully to ascertain if there are any medical conditions (e.g., asthma) which may compromise respiratory function.
2. Tightness and duration of the stabilization must be monitored and reassessed at regular intervals.
3. Stabilization around extremities or the chest must not actively restrict circulation or respiration.
4. Stabilization should be terminated as soon as possible in a pt who is experiencing severe stress or hysterics to prevent possible physical or psychological trauma.

Question 148

What documentation do you need for sedation?

Answer 148

1. Informed consent
2. Instructions and information provided to the parent.
3. Health evaluation
4. A time-based record that includes the name, route, site, time, dosage and pt effect of administered drugs.
5. The pt’s level of consciousness, responsiveness, heart rate, blood pressure, respiratory rate and oxygen saturation at the time of treatment and until predetermined discharge criteria have been attained.
6. Adverse events (if any) and their treatment.
7. Time and condition of the pt at discharge.

Question 149

What are the goals of sedation?

Answer 149

1. Guard the pt’s safety and welfare.
2. Minimize physical discomfort and pain.
3. Control anxiety, minimize psychological trauma and maximize the potential for amnesia.
4. Control behavior and/or movement so as to allow the safe completion of the procedure.
5. Return the pt to a state in which safe discharge from medical supervision, as determined by recognized criteria is possible.

Question 150

When should you use sedation?

Answer 150

Indications:

1. Fearful, anxious pts for whom basic behavior guidance techniques have not been successful.
2. Pts who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical or medical disability.
3. Pts for whom the use of sedation may protect the developing psyche and/or reduce medical risk.

Contraindications:

1. The cooperative pt with minimal dental needs.
2. Predisposing medical and/or physical conditions which would make sedation inadvisable.

Question 151

What is general anesthesia?

Answer 151

General anesthesia is a controlled state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command.

Question 152

What documentation do you need for general anesthesia?

Answer 152

1. Rationale for use of general anesthesia
2. Informed consent
3. Instructions provided to the parent
4. Dietary precautions
5. Preoperative health evaluation

Question 153

What are the minimal requirements for a time-based anesthesia record?

Answer 153

1. The pt’s heart rate, blood pressure, respiratory rate, and oxygen saturation at specific intervals throughout the procedure and until predetermined discharge criteria have been attained.
2. The name, route, site, time, dosage and pt effect of administered drugs, including local anesthesia.
3. Adverse events (if any) and their treatment.
4. That discharge criteria have been met, the time and condition of the pt at discharge and into whose care the discharge occurred.

Question 154

What are the goals of general anesthesia?

Answer 154

The goals of general anesthesia are to:

1. Provide safe, efficient and effective dental care.
2. Eliminate anxiety.
3. Reduce untoward movement and reaction to dental treatment.
4. Aid in treatment of the mentally, physically or medically compromised pt.
5. Eliminate the pt’s pain response.

Question 155

When should you use general anesthesia?

Answer 155

Indications:

1. Pts who cannot cooperate due to alack of psychological or emotional maturity and/or mental, physical or medical disability.
2. Pts for whom local anesthesia is ineffective bc of acute infection, anatomic variations or allergy.
3. The extremely uncooperative, fearful, anxious or uncommunicative child or adolescent.
4. Pts requiring significant surgical procedures.
5. Pts for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk.
6. Pts requiring immediate, comprehensive oral/dental care.

Contraindications:

1. A healthy, cooperative pt with minimal dental needs.
2. Predisposing medical conditions which would make general anesthesia inadvisable.

Question 156

How do you use the Faces Pain Scale - Revised (FPS-R)?

Answer 156

1. Say “hurt” or “pain”, whichever seems right for particular child.
2. These faces show how much something can hurt. The faces on the left shows no pain. The faces show more and more pain.
   - -0 = no pain; 10 = very much pain.
   - -Do not use words like “happy” and “sad.” This scale is intended to measure how children feel inside, not how their face looks.

Question 157

How do you use the Wong-Baker FACES Pain scale?

Answer 157

1. Brief word instructions - point to each face using the words to describe the pain tensity. Ask the child to choose face that best describes own pain and record the appropriate number.
2. Original instructions - explain to the child that each face is for a child who feels happy bc he has no pain (hurt) or sad bc he has some or a lot of pain.
   - -Face 0 is very happy bc he doesn’t hurt at all.
   - -Face 1 hurts just a little bit.
   - -Face 2 hurts a little more.
   - -Face 5 hurts as much as you can image, although you don’t have to be crying to feel bad.
3. Ask the child to choose the face that best describes how he is feeling.
4. Rating scale is recommended for persons age 3 years and older.

Question 158

Describe the Frankl Behavior Rating Scale?

Answer 158

1 – Definitely negative. Refusal of treatment, forceful crying, fearfulness, or any other overt evidence of extreme negativism.
2 - Negative. Reluctance to accept treatment, uncooperative, some evidence of negative attitude but not pronounced (sullen, withdrawn).
3 + Positive. Acceptance of treatment; cautious behavior at times; willingness to comply with the dentist, at times with reservation, but pt follows the dentist’s direction cooperatively.
4 ++ Definitely positive. Good rapport with the dentist, interest in the dental procedures, laughter and enjoyment.

Question 159

What is the “patient-oriented” standard for informed consent?

Answer 159

Currently most states have adopted the “patient-oriented” standard. Thus, a practitioner may be held liable if a parent has not received all of the information that is essential to his/her decision to accept or reject proposed treatment.

Question 160

What are important considerations on parental presence during protective stabilization?

Answer 160

92% of mothers in one study believed they should have been with their child when he/she was placed on a rigid stabilization board to increase the child’s security and/or comfort.

• -Practitioners should consider allowing parental presence in the operatory or direct visual observation of the pt during use of protective stabilization unless the health and safety of the pt, parent or dental staff would be at risk.
• -If parents are denied access, they must be informed of the reason with documentation of the explanation in the pt’s chart.
• -If parents choose not to be present, they should be encouraged to provide positive nurturing support for the child both before and after the procedure.
• -Ultimately, a parent has the right to terminate use of restraint at any time if he or she believes the child may be experiencing physical or psychological trauma due to immobilization. If termination is requested, the practitioner immediately should complete the necessary steps to bring the procedure to a safe conclusion before ending the appointment.

Question 161

What medical history would be important in using protective stabilization?

Answer 161

1. Compromise respiratory function (asthma)
2. Neuromuscular disorder
3. Bone/skeletal disorder

Question 162

What are the ideal characteristics of a mechanical restraining device for protective stabilization?

Answer 162

1. Easily used
2. Appropriately sized for the pt
3. Soft and contoured to minimize potential injury to the pt.
4. Specifically designed for pt stabilization (i.e., not improvised equipment).
5. Able to be disinfected.

Question 163

How should a protective stabilization be removed at the end of a procedure?

Answer 163

At the completion of dental procedures, removal of restraints should be accomplished sequentially with short pauses between stages to assess the pt’s level of cooperation.
–Struggling during removal of restraints may increase the injury to the child as well as others.

Question 164

What can help the pt have a positive experience during administration of local anesthesia?

Answer 164

1. Age-appropriate “nonthreatening” terminology
2. Distraction
3. Topical anesthetics
4. Proper injection technique
5. Nitrous oxide/oxygen analgesia/anxiolysis

Question 165

What are the two general types of local anesthetic chemical formulations?

Answer 165

1. Esters - procaine, benzocaine, tetracaine

2. Amides - lidocaine, mepivicaine, prilocaine, articaine, bupivacaine

Question 166

Why are vasoconstrictors added to local anesthetics?

Answer 166

Vasoconstrictors are added to local anesthetics to constrict blood vessels in the area of injection.
–This lowers the rate of absorption of the local anesthetic into the blood stream, thereby lowering the risk of toxicity and prolonging the anesthetic action int he area.

Question 167

When is local anesthetic with epinephrine contraindicated?

Answer 167

1. Hyperthyroidism - epinephrine is contraindicated.
2. Tricyclic antidepressants - dose should be kept to a minimum since dysrhythmias may occur. Levonordefrin and norepinephrine are absolutely contraindicated in these pts.
3. Pts with significant cardiovascular disease, thyroid dysfunction, diabetes, or sulfite sensitivity and those receiving monoamine oxidase inhibitors, tricyclic antidepressants, or phenothiazines may require a medical consultation to determine the need for a local anesthetic without vasoconstrictor.
4. When halogenated gases (e.g., halothane) are used for general anesthesia, the myocardium is sensitized to epinephrine. Such situations dictate caution with use of a local anesthetic?

Question 168

Are amides local anesthetics contraindicated in pts with a family history of malignant hyperthermia?

Answer 168

No. Amide-type local anesthetics no longer are contraindicated in pts with a family history of malignant hyperthermia (an abnormal elevation in body temperature during general anesthesia with inhalation anesthetics or succinylcholine).

Question 169

What is the importance of injection of local anesthetics into an area of infection?

Answer 169

1. If a local anesthetic is injected into an area of infection, its onset will be delayed or even prevented.
   - -The inflammatory process in an area of infection lowers the pH of the extracellular tissue from its normal value (7.4) to 5 or 6 or lower. This low pH inhibits anesthetic action bc little of the free base form of the anesthetic is allowed to cross into the nerve sheath to prevent conduction of nerve impulses.
2. Inserting a needle into an active site of infection also could lead to possible spread of the infection.

Question 170

Topical anesthetics are effective on what kind of tissues?

Answer 170

Topical anesthetic is effective on surface tissues (up to 2-3 mm in depth) to reduce painful needle penetration of the oral mucosa.

Question 171

What concentrations are the topical anesthetics available in?

Answer 171

1. Benzocaine is manufactured in concentrations up to 20%.

2. Lidocaine is available as a solution or ointment up to 5% and as a spray up to 10% concentration.

Question 172

What are the properties of benzocaine as a topical anesthetic?

Answer 172

1. Benzocaine has a rapid onset.
2. Benzocaine toxic (overdose) reactions are virtually unknown. Localized allergic reactions, however, may occur after prolonged or repeated use.

Question 173

What are the properties of lidocaine as a topical anesthetic?

Answer 173

Topical lidocaine has an exceptionally low incidence of allergic reactions but is absorbed systemically and can combine with an injected amide local anesthetic to increase the risk of overdose.

Question 174

When are compounded topical anesthetics used?

Answer 174

1. Orthodontic procedures for placement of mini-screw implants to aid tooth movement.
2. Pediatric dentistry to anesthetize palatal tissues prior to injection and for extraction of loose primary teeth without the need for an injection.

-The US Food and Drug Administration does not regulate compounded topical anesthetics and recently issued warning about their use.

Question 175

What is the benefit of using larger gauge needles?

Answer 175

Larger gauge needles provide for less deflection as the needle passes through soft tissues and for more reliable aspiration.

Question 176

What lengths and gauges are available for dental needles?

Answer 176

1. Dental needles are available in 3 lengths: long (32mm), short (20mm), and ultrashort (10mm).
   - -Short needles may be used for any injection in which the thickness of soft tissue is less than 20mm.
   - -Long needle may be used for a deeper injection into soft tissue.
2. Needle gauges range from size 23 to 30.
   - -Any 23 through 30 gauge needle may be used for intraoral injections, since blood can be aspirated through all of them.
   - -Aspiration can be more difficult, however, when smaller gauge needles are used.
   - -An extra-short, 30-gauge is appropriate for infiltration injections.

Question 177

When do needle breakage occur?

Answer 177

1. Needle breakage is a rare occurrence.
2. The primary cause of needle breakage is weakening the needle due to bending it before insertion into the soft tissues; another cause is pt movement after the needle is already inserted.
   - -Needles should not be bent if they are to be inserted into soft tissue to a depth of greater than 5mm or inserted to their hub for injections to avoid needle breakage.

Question 178

What is the contraindication for local anesthetics?

Answer 178

1. Absolute contraindications for local anesthetics include a documented local anesthetic allergy.
   - -True allergy to an amide is exceedingly rare.
   - -Allergy to one amide does not rule out the use of another amide, but allergy to one ester rules out use of another ester.
2. A bisulfate preservative is used in local anesthetics containing epinephrine.
   - -For pts having an allergy to bisulfates, use of a local anesthetic without a vasoconstrictor is indicated.
   - -Local anesthetics without vasoconstrictors should be used with caution due to rapid systemic absorption which may result in overdose.

Question 179

Which local anesthetic is not recommended for children?

Answer 179

A long-acting local anesthetic (i.e., bupivacaine) is not recommended for the child or the physically or mentally disabled pt due to its prolonged effect, which increases the risk of soft tissue injury.

Question 180

Can articaine provide lingual or palatal soft tissue anesthesia from a buccal infiltration?

Answer 180

Claims have been made that articaine can diffuse through hard and soft tissue from a buccal infiltration to provide lingual or palatal soft tissue anesthesia.
–Studies using articaine, lidocaine, and prilocaine, however, did not substantiate these claims.

Question 181

When should a vasopressor-containing local anesthetic be used?

Answer 181

1. A vasopressor-containing local anesthetic should be used when treatment extends to two or more quadrants in a single visit.
2. Epinephrine concentrations of 1:50,000 may be indicated for infiltration in small doses into a surgical site to achieve hemostasis but are not indicated in children to control pain.

Question 182

What are the precautions regarding prilocaine?

Answer 182

1. An end product of prilocaine metabolism can induce formation of methemoglobin, reducing the blood’s oxygen-carrying capacity.
2. In pts with subclinical methemoglobinemia or with toxic doses (greater than 6 mg/kg), prilocaine can induce methemoglobinemia symptoms (e.g., gray or slate blue cyanosis of the lips, mucous membranes and nails; respiratory and ciruclatory distress).
3. Prilocaine may be contraindicated in pts with methemoglobinemia, sickle cell anemia, anemia, or symptoms of hypoxia or in pts receiving acetaminophen or phenacetin, since both medications elevate methemoglobin levels.

Question 183

What is the duration of action of lidocaine, articaine and mepivicaine for a maxillary infiltration and mandibular block?

Answer 183

1. Lidocaine 2% + 1:100,000 epinephrine:
   - -Maxillary infiltration - pulp 60 mins, soft tissue 170 mins
   - -Mandibular block - pulp 85 mins, soft tissue 190 mins
2. Articaine 4% + 1:100,000 epinephrine:
   - -Maxillary infiltration - pulp 60 mins, soft tissue 190 mins
   - -Mandibular block - pulp 90 mins, soft tissue 230 mins
3. Mepivacaine 2% + 1:100,000:
   - -Maxillary infiltration - pulp 50 mins, soft tissue 130 mins
   - -Mandibular block - pulp 75 mins, soft tissue 185 mins

Question 184

What is the maximum dosage of lidocaine, articaine and mepivacaine?

Answer 184

1. Lidocaine - 4.4 mg/kg, MRD 300 mg
2. Articaine - 7.0 mg/kg, MRD 500 mg
3. Mepivacaine - 4.4 mg/kg, MRD 300 mg

Question 185

How much anesthetic dosage is in a dental cartridge for lidcoaine, articaine and mepivacaine?

Answer 185

1. Lidocaine 2% + 1:100,000 epinephrine
   - -Anesthetic - 34 or 36 mg/1.7mL or 1.8mL cartridge
   - -Vasoconstrictor - 17 ug or 0.017mg or 18 ug or 0.018mg
2. Articaine 4% +1:100,000 epinephrine
   - -Anesthetic - 68 or 72 mg/1.7mL or 1.8mL cartridge
   - -Vasoconstrictor - 17 ug or 0.017mg or 18 ug or 0.018mg
3. Mepivacaine 2% + 1:100,000 epinephrine
   - -Anesthetic - 34 or 36 mg/1.7mL or 1.8mL cartridge
   - -Vasoconstrictor - 17 ug or 0.017mg or 18 ug or 0.018mg

Question 186

What should be documented regarding local anesthesia?

Answer 186

1. Documentation must include the type and dosage of local anesthetic. Dosage of vasoconstrictors, if any, must be noted. (For example, 34 mg lido with 0.017 mg epi or 34 mg lido with 1:100,000 epi).
2. Documentation may include the type of injection(s) given (e.g., infiltration, block, intraosseous), needle selection, and pt’s reaction to the injection.
3. If the local anesthetic was administered in conjunction with sedative drugs, the doses of all agents must be noted on a time-based record.
4. In pts for whom the maximum dosage of local anesthetic may be a concern, the weight should be documented preoperatively.
5. Documentation should include that post-injection instructions were reviewed with the pt and parent.

Question 187

When do most adverse drug reactions to local anesthetics occur?

Answer 187

Most adverse drug reactions develop either during the injection or within 5 to 10 minutes.
–After the injection, the doctor, hygienist, or assistant should remain with the pt while the anesthetic begins to take effect. Early recognition of a toxic response is critical for effective management.

Question 188

What are the indications of local anesthetic toxicity?

Answer 188

1. CNS
   - -Subjective - dizziness, anxiety, confusion. Followed by diplopia, tinnitis, drowsiness, and circumoral numbness or tingling.
   - -Objective - muscle twitching, tremors, talkativeness, slowed speech, and shivering. Followed by overt seizure activity. Unconsciousness and respiratory arrest may occur.
2. CVS
   - -Initially, heart rate and blood pressure may increase. As plasma levels of the anesthetic increase, however, vasodilatation occurs followed by depression of the myocardium with subsequent fall in blood pressure. Bradycardia and cardiac arrest may follow.

Question 189

How can allergic reaction to local anesthesia manifest?

Answer 189

Urticaria, dermatitis, angioedema, fever, photosensitivity or anaphylaxis.

Question 190

What causes paresthesia after local anesthetic injection?

Answer 190

1. Trauma to the nerve. Among other etiologies, trauma can be caused by the needle during the injection.
2. Hemorrhage in or around the nerve can also cause paresthesia.

Question 191

What local anesthetics have increased risk of paresthesia?

Answer 191

1. Reports of paresthesia are more common with articaine and prilocaine than expected from their frequency of use.
2. Paresthesia is more common with 4% local anesthetics (articaine or prilocaine).

Question 192

How long do most cases of paresthesia last?

Answer 192

Most cases resolve in 8 weeks.

Question 193

What are the complications of post-operative soft tissue trauma after local anesthetic use in the oral cavity?

Answer 193

Most lip and cheek biting lesions of this nature are self-limiting and health without complications, although bleeding and infection possibly may result.

Question 194

Is there a type of local anesthetic injection that may increase the risk of postoperative soft tissue injury?

Answer 194

1. The use of bilateral mandibular blocks does not increase the risk of soft tissue trauma when compared to unilateral mandibular blocks or ipsilateral maxillary infections.
   - -In fact, the frequency of soft tissue trauma was much higher than expected when only one side was anesthetized.
2. Using mandibular infiltration vs blocks is not of great value in prevention of these injuries, since the duration of soft tissue anesthesia may not be reduced significantly.

Question 195

What can be used to reduce the duration of soft tissue anesthesia?

Answer 195

Use of phentolamine mesylate injections in pts over 6 years of age or at least 15 kg has been shown to reduce the duration of effects of local anesthetic by about 47% in the maxilla and 67% in the mandible.
–However, there is no research demonstrating a relationship between reduction in soft tissue trauma and the use of shorter acting local anesthetics.

Question 196

What can you do to reduce local anesthetic complications after the procedure is complete?

Answer 196

1. Advise pts and their caregivers regarding behavioral precautions (e.g., do not bite or suck on lip/cheek, do not ingest hot substances) and the possibility of soft tissue trauma while anesthesia persists.
2. Placing a cotton roll in the mucobuccal fold may help prevent injury.
3. Lubricating the lips with petroleum jelly helps prevent drying.

Question 197

Which supplemental local anesthesia injection requires endocarditis prophylaxis in pts at risk?

Answer 197

Endocarditis prophylaxis is recommended for intraligamentary local anesthetic injections in pts at risk.

Question 198

During pulpal therapy, if other methods fail to anesthetize the tooth, what can you do?

Answer 198

During pulpal therapy, administering local anesthetic directly into the pulp may be indicated when other methods fail to anesthetize the tooth.

Question 199

What is an intraseptal injection?

Answer 199

Intraseptal inejction for lingual anesthesia is a variation in technique after the buccal tissue is anesthetized.

• -The needle is inserted through the buccal tissue to anesthetize the lingual/palatal soft tissues.
• -It can be used with the PDL injection to gain lingual anesthesia when postoperative soft tissue trauma is a concern.

Question 200

When do you use the PDL and intraosseous injection techniques?

Answer 200

1. In patients with bleeding disorders, the PDL injection minimizes the potential for postoperative bleeding of soft tissue vessels.
2. Intraosseous techniques may be contraindicated with primary teeth due to potential for damage to developing permanent teeth.
3. The use of the PDL injection or intraosseus methods is contraindicated in the presence of inflammation or infection at the injection site.

Question 201

For mandibular teeth, what kind of injection can you use?

Answer 201

Mandibular buccal infiltration anesthesia is as effective as inferior nerve block anesthesia for some operative procedures.
–The mandibular bone of a child usually is less than that of an adult, permitting more rapid and complete diffusion of the anesthetic.

Question 202

What are the considerations for local anesthesia with sedation, general anesthesia, and/or nitrous oxide/oxygen analgesia/anxiolysis?

Answer 202

1. An increase in toxic reactions of local anesthetics when combined with opioids has been demonstrated.
   - -Narcotics may decrease the amount of protein binding of local anesthetics and also elevate arterial carbon dioxide, both of which will increase CNS sensitivity to convulsions.
   - -It has been suggested that the dose of local anesthesia be adjusted downward when sedating children with opioids.
2. The dosage of local anesthetic should not be altered if nitrous oxide/oxygen analgesia/anxiolysis administered.
3. When general anesthesia is employed, local anesthesia may be used to reduce the maintenance dosage of inhalation anesthetics.
   - -The anesthesia care provider needs to be aware of the concomitant use of a local anesthetic containing epinephrine, as epinephrine can produce dysrhythmias when used with halogenated hydrocarbons (e.g., halothane).
   - -Local anesthesia also has been reported to reduce pain in the postoperative recovery period after general anesthesia.

Question 203

What is nitrous oxide?

Answer 203

Nitrous oxide is a colorless and virtually odorless gas with a faint, sweet smell.

Question 204

What are the mechanism of action of nitrous oxide?

Answer 204

Nitrous oxide has multiple mechanisms of action.

1. Analgesic effect - appears to be initiated by neuronal release of endogeneous opioid peptides with subsequent activation of opioid receptors and descending Gamma-aminobutyric acid type A (GABAA) receptors and noradrenergic pathways that modulate nociceptive processing at the spinal level.
2. Anxiolytic effect - invovles activation of the GABAA receptor eitehr directly or indirectly through the benzodiazepine binding site.

Question 205

What are the precautions for diffusion hypoxia after nitrous oxide use?

Answer 205

1. As nitrous oxide is 34 times more soluble than nitrogen in blood, diffusion hypoxia may occur.
2. Administering 100% oxygen to the pt once the nitrous oxide in a closed system has been terminated is important.

Question 206

What are the effects of nitrous oxide on the cardiovascular system?

Answer 206

Nitrous oxide causes minor depression in cardiac output while peripheral resistance is slightly increased, thereby maintaining the blood pressure.
–This is of particular advantage in treating pts with cerebrovascular system disorders.

Question 207

What are the safety benefits of using nitrous oxide?

Answer 207

1. Nitrous oxide is absorbed rapidly, allowing for both rapid onset and recovery (2 to 3 minutes).
2. It causes minimal impairment of any reflexes, thus protecting the cough reflex.
3. It exhibits a superior safety profile with no recorded fatalities or cases of serious morbidity when used within recommended concentrations.
4. Studies have reported negative outcomes associated with use of nitrous oxide greater than 50% and as an anesthetic during major surgery.
5. Although rare, silent regurgitation and subsequent aspiration need to be considered with nitrous oxide/oxygen sedation. The concern lies in whether pharyngeal-laryngeal reflexes remain intact. This problem can be avoided by not allowing the pt to go into an unconscious state.

Question 208

What is the bioenvironmental concern with nitrous oxide?

Answer 208

1. Nitrous oxide has been associated with bioenvironmental concerns bc of its contribution to the greenhouse effect.
2. Nitrous oxide is emitted naturally bacteria in soils and oceans; it is produced by humans through the burning of fossil fuels and forests and the agricultural practices of soil cultivation and nitrogen fertilization.
   - -Altogether nitrous oxide contributes about 5% to the greenhouse effect. Only a small fraction of this 5% (0.35 to 2%), however, is actually the result of combined medical adn dental applications of nitrous oxide.

Question 209

What are the objectives of nitrous oxide/oxygen inhalation?

Answer 209

1. Reduce or eliminate anxiety.
2. Reduce untoward movement and reaction to dental treatment.
3. Enhance communication and pt cooperation.
4. Raise the pain reaction threshold.
5. Increase tolerance for longer appointments.
6. Aid in treatment of the mentally/physically disabled or medically compromised pt.
7. Reduce gagging.
8. Potentiate the effect of sedatives.

Question 210

What are the disadvantages of nitrous oxide/oxygen inhalation?

Answer 210

1. Lack of potency.
2. Dependent largely on psychological reassurance.
3. Interference of the nasal hood with injection to anterior maxillary region.
4. Pt must be able to breathe through the nose.
5. Nitrous oxide pollution and potential occupational exposure health hazards.

Question 211

What are the indications for use of nitrous oxide/oxygen analgesia/anxiolysis?

Answer 211

1. A fearful, anxious, or obstreperous pt.
2. Certain pts with special health care needs.
3. A pt whose gag reflex interferes with dental care.
4. A pt for whom profound local anesthesia cannot be obtained.
5. A cooperative child undergoing a lengthy dental procedure.

Question 212

What are the contraindications for use of nitrous oxide/oxygen inhalation?

Answer 212

1. Some chronic obstructive pulmonary diseases.
2. Severe emotional disturbances or drug-related dependencies.
3. First trimester of pregnancy.
4. Treatment with bleomycin sulfate.
5. Methylenetetrahydrofolate reductase deficiency.
6. Cobalamin deficiency.

-Whenever possible, appropriate medical specialists should be consulted before administering analgesic/anxiolytic agents to pts with significant underlying medical conditions (e.g., severe obstructive pulmonary disease, congestive heart failure, sickle cell disease, acute otitis media, recent tympanic membrane graft, acute severe head injury).

Question 213

What is the technique of nitrous oxide/oxygen administration?

Answer 213

1. A flow rate of 5 to 6 L/min generally is acceptable to most pts.
   - -The flow rate can be adjusted after observation of the reservoir bag. The bag should pulsate gently with each breath and should not be either over or underinflated.
2. Introduction of 100% oxygen for 1 to 2 minutes followed by titration of nitrous oxide in 10% intervals is recommended.
3. The concentration of nitrous oxide should not routinely exceed 50%. The typical pt requires from 30 to 40% nitrous oxide to achieve ideal sedation.
   - -Nitrous oxide concentration may be decreased during easier procedures (e.g., restorations) and increased during more stimulating ones (e.g., extraction, injection of local anesthetic).
   - -Side effects such as nausea and vomiting are more likely to be observed when titration is not employed.
4. The effects of nitrous oxide largely are dependent on psychological reassurance. Therefore, it is important to continue traditional behavior guidance techniques during treatment.
5. Once the nitrous oxide flow is terminated, 100% oxygen should be delivered for 5 minutes. The pt must return to pretreatment responsiveness before discharge.

Question 214

What adverse effects of nitrous oxide/oxygen inhalation can occur?

Answer 214

1. Nausea and vomiting are the most common adverse effects, occurring in 0.5% of pts.
   - -A higher incidence is noted with longer administration of nitrous oxide/oxygen, fluctuations in nitrous oxide levels, and increased concentrations of nitrous oxide.
   - -Fasting is not required for pts undergoing nitrous oxide analgesia/anxiolysis. The practitioner, however, may recommend that only a light meal be consumed int he 2 hours prior to the administration of nitrous oxide.
2. Diffusion hypoxia can occur as a result of rapid release of nitrous oxide from the blood stream into the alveoli, thereby diluting the concentration of oxygen.
   - -This may lead to headache and disorientation and can be avoided by administering 100% oxygen after nitrous oxide has been discontinued.

Question 215

What documentation is necessary for use of nitrous oxide?

Answer 215

1. Informed consent
2. Instructions to the parent regarding pretreatment dietary precautions, if indicated.
3. Pt’s record should include - indication for use of nitrous oxide/oxygen inhalation, nitrous oxide dosage (i.e., percent nitrous oxide/oxygen and/or flow rate), duration of the procedure and post treatment oxygenation procedure.

Question 216

What must you have if you have a nitrous/oxygen delivery equipment capable of delivering more than 70% nitrous oxide and less than 30% oxygen?

Answer 216

If nitrous oxide/oxygen delivery equipment capable of delivering more than 70% nitrous oxide and less than 30% oxygen is used, an inline oxygen analyzer must be used.

Question 217

What emergency cart equipment is necessary for nitrous oxide use?

Answer 217

1. Training and certification in basic life support are required for all clinical personnel.
2. A positive pressure oxygen delivery system capable of administering greater than 90% oxygen at a 10 L/min flow for at least 60 minutes (650 L, “E” cylinder) must be available.
3. When a self-inflating bag valve mask device is used for delivering positive pressure oxygen, a 15 L/min flow is recommended.

Question 218

What can happen with long-term exposure to nitrous oxide?

Answer 218

In the medical literature, long-term exposure to nitrous oxide used as a general anesthetic has been linked to bone marrow suppression and reproductive system disturbances.

Question 219

What age group of children typically require deep levels of sedation?

Answer 219

Often, children younger than six years and those with developmental delay require deep levels of sedation to gain control of their behavior.
–Children in this age group are particularly vulnerable to the sedating medication’s effects on respiratory drive, patency of the airway and protective reflexes.

Question 220

What is minimal sedation?

Answer 220

1. Old terminology “anxiolysis.”
2. A drug-induced state during which pts respond normally to verbal commands.
3. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Question 221

What is moderate sedation?

Answer 221

1. Old terminology “conscious sedation” or “sedation/analgesia.”
2. A drug-induced depression of consciousness during which pts respond purposefully to verbal commands (e.g., “open your eyes” either alone or accompanied by light tactile stimulation - a light tap on the shoulder or face, not a sternal rub).
3. For older pts, this level of sedation implies an interactive state; for younger pts, age-appropriate behaviors (e.g., crying) occur and are expected.
4. Reflex withdrawal, although a normal response to a painful stimulus, is not considered as the only age-appropriate purposeful response (e.g., it must be accompanied by another response, such as pushing away the painful stimulus so as to confirm a higher cognitive function).
5. With moderate sedation, no intervention is required to maintain a patent airway and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. However, in the case of procedures that may themselves cause airway obstruction (e.g., dental or endoscopic), the practitioner must recognize an obstruction and assist the pt in opening the airway.
   - -If the pt is not making spontaneous efforts to open his/her airway so as to relieve the obstruction, then the pt should be considered to be deeply sedated.

Question 222

What is deep sedation?

Answer 222

1. “Deep sedation/analgesia”
2. A drug-induced depression of consciousness during which pts cannot be easily aroused but respond purposefully (see discussion of reflex withdrawal in moderate sedation) after repeated verbal or painful stimulation (e.g., purposefully pushing away the noxious stimuli).
3. The ability to independently maintain ventilatory function may be impaired. Pts may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. A state of deep sedation may be accompanied by partial or complete loss of protective airway reflexes.

Question 223

What is general anesthesia?

Answer 223

1. A drug-induced loss of consciousness during which pts are not arousable, even by painful stimulation.
2. The ability to independently maintain ventilatory function is often impaired. Pts often require assistance in maintaining a patent airway and positive-pressure ventilation may be required bc of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

Question 224

What are the goals of sedation?

Answer 224

1. To guard the pt’s safety and welfare.
2. To minimize physical discomfort and pain.
3. To control anxiety, minimize psychological trauma and maximize the potential for amnesia.
4. To control behavior and/or movement so as to allow the safe completion of the procedure.
5. To return the pt to a state in which safe discharge from medical supervision, as determined by recognized criteria, is possible.

Question 225

When are adverse outcomes increased when administering sedation medications?

Answer 225

The potential for an adverse outcome may be increased when 3 or more sedating medications are administered.

Question 226

When do you need to have longer periods of observation after sedation?

Answer 226

1. Drugs with long durations of action (e.g., chloral hydrate, intramuscular pentobarbital, phenothiazines) will require longer periods of observation, even after the child achieves currently used recovery and discharge criteria.
   - -This concept is particularly important for infants and toddlers transported in car safety seats who are at risk of resedation after discharge bc of residual prolonged drug effects with the potential for airway obstruction.
2. Pts who have received reversal agents, such as flumazenil or naloxone, will also require a longer period of observation, bc the duration of the drugs administered may exceed the duration of the antagonist which can lead to resedation.
3. Consideration for a longer period of observation shall be given if the responsible person’s ability to observe the child is limited (e.g., only one adult who also has to drive.)
4. Another indication for prolonged observation would be a child with an anatomic airway problem or severe underlying medical condition.

Question 227

What types of pts are appropriate candidates for minimal, moderate or deep sedation?

Answer 227

1. Pts who are in ASA classes I and II are frequently considered appropriate candidates for minimal, moderate, or deep sedation.
2. Children in ASA classes III and IV, children with special needs, and those with anatomic airway abnormalities or extreme tonsillar hypertrophy present issues that require additional and individual consideration, particularly for moderate and deep sedation.

Question 228

How many adults should accompany a pediatric pt for sedation?

Answer 228

1. The pediatric pt shall be accompanied to and from the treatment facility by a parent, legal guardian, or other responsible person.
2. it is preferable to have 2 or more adults accompany children who are still in car safety seats if transportation to and from a treatment facility is provided by one of the adults.

Question 229

What documentation is necessary before sedation?

Answer 229

1. Informed consent
2. Instructions and information provided to the responsible person.
   - -The practitioner shall provide verbal and/or written instructions to the responsible person.
   - -Information shall include objectives of the sedation and anticipated changes in behavior during and after sedation.
   - -Special instructions shall be given to the adult responsible for infants and toddlers who will be transported home in a car safety seat regarding the need to carefully observe the child’s head position so as to avoid airway obstruction. Transportation by care safety seat poses a particular risk for infants who have received medications known to have a long half-life such as chloral hydrate, intramuscular pentobarbital, or phenothiazine.
   - -A 24-hour telephone number for the practitioner or his or her associates shall be provided to all pts and their families. Instructions shall include limitations of activities and appropriate dietary precautions.

Question 230

Why are the dietary precautions for sedation the same as for general anesthesia?

Answer 230

It is likely that the risk of aspiration during procedural sedation differs from that during general anesthesia involving tracheal intubation or other airway manipulation.
–However, bc the absolute risk of aspiration during procedural sedation is not yet known, guidelines for fasting periods before elective sedation generally should follow those used for elective general anesthesia.

Question 231

What is the appropriate intake of food and liquids before elective sedation?

Answer 231

• 2 hrs minimum fasting period - clear liquids: water, fruit juices without pulp, carbonated beverages, clear tea, black coffee.
• 4 hrs minimum fasting period - breast milk
• 6 hrs minimum fasting period - Infant formula
• 6 hrs minimum fasting period - nonhuman milk: bc nonhuman milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period.
• 6 hrs minimum fasting period - light meal: a light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of foods ingested must be considered when determining an appropriate fasting period.

–It is permissible for routine necessary medications to be taken with a sip of water on the day of the procedure.

Question 232

What types of nonfasted emergency pts may require careful evaluation before administration of sedation?

Answer 232

Pts with a history of recent oral intake or with other known risk factors, such as trauma, decreased level of consciousness, extreme obesity, pregnancy or bowel motility dysfunction require careful evaluation before administration of sedatives.

Question 233

What consideration should be given for the use of immobilization devices in a sedation pt?

Answer 233

1. Immobilization devices, such as papoose boards, must be applied in such a way as to avoid airway obstruction or chest restriction.
2. If an immobilization device is used, a hand or foot should be kept exposed, and the child should never be left unattended.

Question 234

What documentation is needed before sedation?

Answer 234

1. Health evaluation - purpose is to document baseline status and determine whether pts present specific risk factors that may warrant additional consultation before sedation.
2. Prescriptions - a copy of the prescription should be in the pt’s chart along with a description of the instructions that were given to the responsible person.
   - -Prescription medications intended to accomplish procedural sedation must not be administered without the benefit of direct supervision by trained medical personnel.
   - -Administration of sedating medications at home poses an unacceptable risk, particularly for infants and preschool-aged children traveling in car safety seats.

Question 235

What should the health evaluation include?

Answer 235

1. Age and weight.
2. Health history.
3. Review of systems.
4. Vital signs, including heart rate, blood pressure, respiratory rate and temperature (for some children who are very upset or noncooperative, this may not be possible and a note should be written to document this occurrence).
5. Physical exam
6. Physical status evaluation (ASA classification)
7. Name, address, and telephone number of the child’s medical home.

Question 236

What medications may interfere with drug absorption or metabolism?

Answer 236

1. A new concern for the practitioner is the widespread use of medications that may interfere with drug absorption or metabolism and, therefore, enhance or shorten the effect time of sedating medications.
   - -Herbal medicines (e.g., St. John’s wort, echinacea) may alter drug pharmacokinetics through inhibition of the cytochrome P450 system, resulting in prolonged drug effect and altered (increased or decreased) blood drug concentrations.
   - -Kava may increase the effects of sedatives by potentiating gamma-aminobutyric acid inhibitory neurotransmission and valerian may itself produce sedation that apparently is mediated through modulation of gamma-aminobutyric acid neurotransmission and receptor function.
   - -Drugs such as erythromycin, cimetidine, and others also may inhibit the cytochrome P450 system, resulting in prolonged sedation with midazolam as well as other medications competing for the same enzyme systems.

Question 237

What documentation is needed during sedation treatment?

Answer 237

1. Time-based record that includes the name, route, site, time dosage, and pt effect of administered drugs.
2. Before sedation, a “time out” should be performed to confirm the pt’s name, procedure to be performed and site of the procedure.
3. The pt’s chart shall contain documentation at the time of treatment that the pt’s level of consciousness and responsiveness, heart rate, blood pressure, respiratory rate and oxygen saturation were monitored until the pt attained predetermined discharge criteria.

Question 238

What documentation is needed after sedation treatment?

Answer 238

The time and condition of the child at discharge from the treatment area or facility shall be documented - includes documentation that the child’s level of consciousness and oxygen saturation in room air have returned to a state that is safe for discharge by recognized criteria.

Question 239

What is a simple evaluation tool for discharge?

Answer 239

A recently described and simple evaluation tool may be the ability of the infant or child to remain awake for at least 20 minutes when placed in a quiet environment.

Question 240

What are the preparation and setting up for sedation procedures?

Answer 240

A commonly useful acronym useful in planning and preparation for a procedure is SOAPME:
S = Size-appropriate suction catheters and a functioning suction apparatus (e.g., Yankauer-type suction).
O = An adequate oxygen supply and functioning flow meters/other devices to allow its delivery.
A = Airway: size-appropriate airway equipment (nasopharyngeal and oropharyngeal airways, larygoscope blades (checked and functioning), endotracheal tubes, stylets, face mask, bag-valve-mask or equivalent device (functioning).
P = Pharmacy: all the basic drugs needed to support life during an emergency, including antagonists as indicated.
M = Monitors: functioning pulse oximeter with size-appropriate oximeter probes and other monitors as appropriate for the procedure (e.g., noninvasive blood pressure, end-tidal carbon dioxide, ECG, stethoscope).
E = Special equipment or drugs for a particular case (e.g., defibrillator).

Question 241

What are the guidelines for minimal sedation?

Answer 241

Children who have received minimal sedation generally will not require more than observation and intermittent assessment of their level of sedation.
–Some children will become moderately sedated despite the intended level of minimal sedation; should this occur, the the guidelines for moderate sedation apply.

Question 242

What are the guidelines for moderate sedation?

Answer 242

Practitioner:
1. The practitioner must be trained in, and capable of providing, at the minimum, bag-valve-mask ventilation so as to be able to oxygenate a child who develops airway obstruction or apnea.

Support Personnel:

1. The use of moderate sedation shall include provision of a person, in addition to the practitioner, whose responsibility is to monitor appropriate physiologic parameters and to assist in any supportive or resuscitation measures, if required.
2. This individual may also be responsible for assisting with interruptible pt-related tasks of short duration.
3. This individual must be trained in and capable of providing pediatric basic life support.

Monitoring and Documentation:

1. Baseline - baseline determination of vital signs should be documented. For some children who are very upset or noncooperative, this may not be possible and a note should be written to document this happenstance.
2. During the procedure - document the name, route, site, time of administration, and dosage of all drugs administered.
   - -Continuous monitoring of oxygen saturation and heart rate.
   - -Intermittent recording of respiratory rate and blood pressure.
3. After the procedure - the child who has received moderate sedation must be observed in a suitably equipped recovery facility (e.g., the facility must have functioning suction apparatus as well as the capacity to deliver more than 90% oxygen and positive-pressure ventilation (e.g., bag and mask with oxygen capacity as described previously).
   - -The pt’s vital signs should be recorded at specific intervals.
   - -If the pt is not fully alert, oxygen saturation and heart rate monitoring shall be used continuously until appropriate discharge criteria are met.

Question 243

What are the guidelines for deep sedation?

Answer 243

Personnel

1. There must be one person available whose only responsibility is to constantly observe the pt’s vital signs, airway patency and adequacy of ventilation and to either administer drugs or direct their administration.
2. At least one individual must be present who is trained in, and capable of, providing advanced pediatric life support, and who is skilled in airway management and cardiopulmonary resuscitation; training in pediatric advanced life support is required.

Equipment
1. In addition to the equipment previously cited for moderate sedation, an electrocardiographic monitor and a defibrillator for use in pediatric pts should be readily available.

Vascular access
1. Pts receiving deep sedation should have an intravenous line placed at the start of the procedure or have a person skilled in establishing vascular access in pediatric pts immediately available.

Monitoring and documentation

1. The monitoring shall include all parameters described for moderate sedation.
2. Vital signs, including oxygen saturation and heart rate, must be documented at least every 5 minutes in a time-based record.
3. The use of a precordial stethoscope or capnograph for pts difficult to observe (e.g., during MRI, in a darkened room) to aid in monitoring adequacy of ventilation is encouraged.

Question 244

What properties of pulse oximetry are good?

Answer 244

1. The new generation of pulse oximeters is less susceptible to motion artifacts and may be more useful than older oximeters that do not contain the updated software.
2. Oximeters that change tone with changes in hemoglobin saturation provide immediate aural warning to everyone within hearing distance.

Question 245

How are the vast majority of sedation complications managed?

Answer 245

The vast majority of sedation complications can be managed with simple maneuvers, such as supplemental oxygen, opening the airway, suctioning, and bag-mask-valve ventilation.

Question 246

What can expired carbon dioxide monitoring tell you?

Answer 246

Expired carbon dioxide monitoring is valuable to diagnose the simple presence or absence of respirations, airway obstruction, or respiratory depression, particularly in pts sedated in less-accessible locations, such as magnetic resonance imaging or computerized axial tomography devices or darkened rooms.

Question 247

What is the ASA Physical Status Classification?

Answer 247

Class I - a normally healthy pt.
Class II - a pt with mild systemic disease (e.g., controlled reactive airway disease).
Class III - a pt with severe systemic disease (e.g., a child who is actively wheezing).
Class IV - a pt with severe systemic disease that is a constant threat to life (e.g., a child with status asthmaticus).
Class V - a moribund pt who is not expected to survive without the operation (e.g., a pt with severe cardiomyopathy requiring heart transplantation).

Question 248

What are the recommended discharge criteria?

Answer 248

1. Cardiovascular function and airway patency are satisfactory and stable.
2. The pt is easily arousable, and protective reflexes are intact.
3. The pt can talk (if age appropriate).
4. The pt can sit up unaided (if age appropriate).
5. For a very young or handicapped child incapable of the usually expected responses, the presedation level of responsiveness or a level as close as possible to the normal level for that child should be achieved.
6. The state of hydration is adequate.