Paeds Flashcards
What is RA?
It is relative analgesia
What do you need to realise about RA?
RA is not a magic bullet as behaviour management skills are still essential.
What is conscious sedations?
It is when the patient maintain airways independently and continuously.
You have intact pharyngeal and laryngeal relfex
What are the goals of RA?
- Facilitate the provision of quality care
- Minimise the extremes of disruptive behaviour
- Decrease anxiety
- Promote patient welbeing and safety
- Return the patient to a psychological state in which safe discharge is possible
What are the indications of RA?
- Anxious patient
- Older children with poor dental experiences
- Complex or long procedures
- Child with special needs
- Fear of needles
- To aid analgesia
- Increased gage reflex
- AND MEDICALLY FIT ASA I AND ASA II
What are the pharmacology of nitrous oxide?
It has very low solubility in blood. It is absorbed rapidly through the pulmonary alveoli and enters the serum. It acts on the cental nervous system through crossing blood brain barrier. Peak effect achieved within 3-5 minutes. Rapid and complete recovery.
What are physiological effects of nitrous oxide?
- CNS euphoric and depressant effect
- Still responds to instruction
- Children are more relaxed and feel happier
What is the theory behind the work of the RA?
Maybe the GABAA receptors or opioid receptors f the CNS.
What are the adverse effects of RA?
Mostly associated with overdose! Following:
- Nausea or vomiting
- Sleep
- Visual disturbance
- Excessive laughing
- Sweating
What are the signs of over-sedation?
- Detachment/dissociation
- Dreaming, hallcination or fantasizing
- Out of body experiences
- Floating or flying
- Inability to move
- Humming
What to do if you feel like you overdoing the RA?
- Slow induction
- Keep N2O concentration below 50%
- Reduce N2O concentration slowly
- Monitor patent closely
What the 3 purposes of reservoir bag?
- Provide a source of additional gas should the patient inspire more gas than is being supplied ◦
- Provides a mechanism for monitoring the patient’s respiration (watch the expansion and contraction of the bag) and for adjusting the flow (not too stretched or collapsed)
- Functions in an emergency as a method of providing positive pressure oxygen
What do you need to do before RA?
- Parents must sign a consent form
- Make sure equipment is set up properly BEFORE the patient comes in
- Patient must cooperate
What is the difference between slow vs rapid induction?
Slow – best suited for inexperienced operators. Increase from 0-30% in 10% intervals every 1 minutes
Rapid – better for young children – jump to higher concertation
What is the technique to get the patient to get off the RA?
5 minutes of pure oxygen
What do you put in a patient record for RA?
- Signed consent form
- Indication of use
- Nitrous oxide dosage
- Patient response
Why do we start in the waiting room to meet the child?
- First impression matter
- Assessment of the child’s behaviour
- To greet the child
- To compliment a child in order to build rapport
How to talk to a child?
- Act natural
- Make an effort
- Find the point of ice breaking such as compliments, pets or school
What are the process of basic examination for children?
- Get their chief concerns
- Take a useful history – utilise the parent and the child
- Past medical history – are there complciations in the child hood or dental development – tell tutor
- Past dental history – attendance patterns, past caries rate, diet, oral hygiene
- Social history – who is looking after the kid, are there any syblings?
- Exam – extra and intraoral, teeth present, restorations, CPI and caries risk
- Other findings – tooth wear, hypomin, dental anomalies, dental development anomalies and occlusion – know histological staging, calcification time, eruption times in both primary and permanent dentitions
- Practice appropriate and effective communication between the child and yourself and parent and yourself
What are contraindication for RA
Pulmonary heart disease
Sever asthma
Blocked nose
Refusal to breathe through nose
CNS disease
Otitis media or middle year disturbance/surgery - only active
Claustrophobia
GI issues
Cystic fibrosis
How do you administer RA?
Use slow induction technique – from zero to desired 10% at a time per minute
Keep N2O concentration below 50%
Reduce concentration N2O
If patient falls asleep, turn O2 to 100%
Avoid fluctuations
Monitor patient closely
Use 100% of oxygen for 5 minutes at the end of the session
What is the equipment for the nitrous oxide machine?
- Gas delivery machine – continuous flow of O2 and N2O, minimum 2.5L/minute, for children 4-5/L
- Nasal hood – various sizes and flavours
- Inflatable bag – provide source of additional gas, mechanisms for patient respiration, in emergency used as a method of providing positive pressure oxygen
- Scavenging system – to trap experied gas by the patient
- O2 flush valve – in emergency to provide jet ventilation, can cause barotrauma
What sould we record in RA notes?
- Signed informed consent
- Indications of Use
- Nitrous oxide dosage in percent of N2O and O2 with flow rates and duration of the procedure
- Patient response
Is it a legal requirement for a dentist to report child abuse?
Yes
What is important about mandatory reporting?
It is in the name, it is mandatory, you need to do it. For anyone under 18.
When can you report child abuse?
Even if you have a suspicion, you can. It is not a crime to be wrong, but a child’s life can be saved. Even if you are not at work, in a car park for example, you should report it.
When would you not report abuse?
- IF there is a reasonable belief that another person has reported abuse
- IF the suspecion was due soley to being informed of the abuse by a police officer or child protection officer
What are some oral signs of abuse on a child?
Bruising, abrasion, laceration
Dental fractures
Jaw fracture
Sever Dental neglect – not the most accurate but could be possible
Signs of sexual abuse like mucosal injuries that are suspecious
Head and neck injuries that are unexplained well and are suspecious
Bite marks
Withdrawn behavior and extreme fear
What are the eruptions times for deciduous teeth?
- Lower central incisors – 6-10 months
- Upper Central inicsor – 8-12 months
- Upper Lateral inicsor – 9-13 months
- Lower lateral incosr – 10-16
- Upper First molar – 13-19 months
- Lower First Molar – 14-18
- Upper Canine – 16-22 months
- Lower canine – 17-23 months
- Lower seond molar – 23-31 months
- Upper Second molar 25-33 months
What are the eruption times for permanent teeth?
1.Lower central incisors – 6-7 years
2.Upper First molar – 6-7 years
3.Lower First molar – 6-7 years
4.Upper Central Incisors – 7-8 years
5.Lower Lateral Incisors – 7-8 years
6.Upper Lateral Incisors – 8-9 years
7.Lower canine – 9-10 years old
8.Upper first premolar – 10-11 years
9.Lower first premolar – 10-12 years
10.Upper second premolar – 10-12 years
11.Upper cannines – 11-12 years old
12.Lower second molar – 11-13 years old
13.Upper second molar – 12-13 years old
14.All third molars 17-21 years old
What are some learning theories?
- Classic: stimulus resposnse ie white coat = needle
- Operant: action reenforced with a rewards or punishment .
- Social: modeling – very good, monkey see monkey do
What is one of the best way to influence a child?
Positive reinforcement – all adults and children are influenced by reinforcement. This is also very relevant for small children. The more consistent the reinforcement, the more likely a desired behaviour is reached. ALWAYS BE PRAISING. PLEASE SAY PLEASE AND THANK YOU. Be specific and consistent with your praise
What are some of the positive reinforcements?
- Motivational advice
- Verbal praise, non-verbal such as smile or STICKERS
What are inappropriate reinforcers in clinic?
1.Sweets or other food as praise.
2.Punishment – literally does not work
What is the Frankl scale?
It is a scale of co-operation and fears. Please put it into notes. Uses ++, +, -, – scale for general idea.
What is the Wrigth scale?
Similar to Frankl scale but it uses: Cooperative, potentially cooperative and lacking in cooperative ability
What are some aspects of child management?
1.Time efficiency – kids do not like to sit in the chair for too long
2.Behaviour management techniques: Modelling for the first visit, Tell-Show-Do to reduce anxiety, Voice control do not yell, Use of appropriate language to the kid like euphemism (sleep juice from a magic wand), monitoring the child for sense of control, distractions with triplex or wrigling the toes, positive reinfocement, systemic desensitazantion (a bit advanced and for older children because they realise that fear is irrational), behaviours shaping where you slowly shape the child behaviour from non-cooperative to cooperative with ability to retrace your steps
3.If the kids is dangerous, you can use aversie conditioning BUT NOT IN AUSTRALIA you can just do GA
4.Do not do the treatment if child does not cope with it, it is about quality treatment and overall positive treatment outcomes
What do you do if during tell-show-do exercise a child retracks their hand fromt eh prophy brush?
1.Retrace your steps. The show componenet needs to be modified
2.Ask the child how they are feeling, if they are withdrawn they are probably just anxious
3.Maybe to give them a more sense of control, do it on your fingernail first
4.Then let a child hold a hand mirror next to your finger to give them a sense of control
5.After do it on their finger
6.And finally on their tooth
7.Praise the child for being brave
8.Promise a sticker if you can do it on al teeth – children love stickers
What are the pharmacological agents used in managing behavior?
1.Conscious sedation
2.Deep sedation
3.General anesthesia
What are factors to consider for pharmacological intervention for behaviour management?
1.Patient age
2.Patienet behaviour
3.Treatment required
4.Medical condiitons
5.Distance travelled
6.Language barrier
7.Risk and benefits
8.Practitioner experience
9.Informed consent
What is improtant to understand pain?
Do not be scared to use LA as pain control is the most improtant part of behavior management. Remember about post-operative pain control aswell.
What is the recommended dose of lignocaine in children?
4.4. mg/kg and one carpule has 44mg. So per every 10 kg you can have 1 carpule max. So for a 25 kg child you can have 2-3 carpule with some interspacing. Also remember about topical.0.1g has about 5 mg!
What are the most common complicationa fter LA for a child?
1.Soft tissue trauma
2.Overdose – CNS depression, seizures, decrease cardiac output and cardiovascular collapse
What is the recommended dose of articaine 4%?
It is half of that of lignocaine, so if you use 3 carpules for ligno, use 1.5 for articaine.
What is a good anesthetic to use for a lower molar restoration in children?
Lower molar IANB with lignocaine 2%
How do we administer local to a kid?
1.Tell them about the taste
2.Supraperiosteal infiltration for upper only
3.Inferior alveolar block with long buccal
4.How is the syringe passed is important – under the chair
5.Inject slowly
6.Use behavior management in conuction with pharmacological one