Esther Yang, DDS April 7, 2018

What actually happens in a

Pediatric Dental Office?

EstherYang,DDSApril7,2018

• Chief of ServiceDepartment of Dental SurgeryTexas Children’s Hospital• Adjunct Clinical Assistant Professor Department of Pediatric Dentistry UT School of Dentistry at Houston

NoDisclosures

• NeitherI,normembersofmyimmediatefamily,haveanyfinancialrelationshipswithcommercialentitiesthatmayberelevanttothispresentation.

April 9, 2018 Baylor College of Medicine 2

Disclaimers

• TheopinionsexpressedinthispresentationarethoseofthespeakerandnotnecessarilythoseoftheTexasChildren’sHospital.

• Theopinionsexpressedinthiscourseshouldnotbeconstructedasadvicetocareforspecificpatients.


CourseObjectives

– CollaboratewithDentalprovidertointegratehealthcareneeds.

– Identifyspecialconsiderationssuchas:labvalues,medications,andantibioticprophylaxis

– Assessingdentalemergencies.


Dental Home

• The American Academy of Pediatric Dentistry indicates that an establishment of a Dental Home no later than 12 months of age.

GatheringinformationanddevelopingaplanwithHealthcareprovider• Identifydentaltreatmentneeds• Assesspediatricpatientcompliance.• Identifybesttreatmentmodalityforpatients.• Identifymedicalstatusandcommunicatewith

primarycareprovider• HistoryandPhysical,medicalclearances.


Typical Pediatric Patients

• Definitely Positive• Interest in Dental

procedures• Good Rapport with

Dentist

• Definitely Negative• Refusal of treatment• Forceful crying• Fearfulness

PatientCompliance


What is our GOAL?

• TO MAKE OUR PEDIATRIC PATIENTS AND THEIR PARENTS AS COMFORTABLE AS POSSIBLE!

• Childlife Specialist, behavior therapist

Basic Behavior GuidanceTell Show Do

Voice Control

Non-verbal communication

Positive Reinforcement

Advanced Behavior Guidance

1. Protective Stabilization2. Nitrous Oxide3. Sedation4. General Anesthesia

Protective Stabilization(Papoose Board)

Protective Stabilization

• Parent places child in papoose• Parent present during treatment• Dentist removes patient from papoose at end of procedure• Consent from parent• Used as behavior as management• Social stigma of papoose• Indications:

– Emergency– Previously cooperative and became uncooperative mid treatment– Uncooperative with limited treatment unable to undergo

sedation– Sedated patient with untoward movements

Nitrous Oxide … Laughing Gas

Nitrous Oxide :Pros/Cons

• Pros: Anxiolysis, Analgesic, Decrease Gag Reflex, Increase tolerance for longer appointments, potentiate effects of sedatives, Favorable parental and patient acceptance

• Cons: Nausea, vomiting, diffusion hypoxia, lack of potency, dependant on psychological reassurance, interference of nasal hood with injection in maxillary region, ability to breath through nose

Nitrous Oxide: Contraindication

• Some chronic obstructive pulmonary diseases• Severe emotional disturbances (Cleft Lip &

Palate) drug-related dependencies• First trimester of pregnancy• Treatment with Bleomycin sulfate• Methylenetetrahydrofolate (MTHFR)

reductase deficiency• Vitamin B12 (Cobalamin) deficiency• Acute Otitis Media

Oral Sedation Sedation vs. Screamation

• Demerol, Phenergan, Nitrous Oxide, & 2% Lidocaine w/1:100,000 epinephrine

• Demerol, Hydroxyzine, Nitrous Oxide & 2% Lidocaine w/1:100,000 epinephrine

• Chloral Hydrate, Nitrous Oxide & 2% Lidocaine w/1:100,000 epinephrine

• Versed, Nitrous Oxide & 2% Lidocaine w/1:100,000 epinephrine

Sedation:Pros/Cons

• Pros:•Patient does not “remember” the event.•“less traumatizing”•Financial•Availability

• Cons:• Still need papoose board• Need to carefully monitor due to increased risk• Parents in vs out of room• Costs• Predictability varies• Treatment amount

General Anesthesia

• Pros:• Can perform all treatments in one visit• Cooperation

• Cons:• Long waiting time• Increased risks• Costs

HistoryandPhysicalMedicalclearances.

• Types of Procedures:

– Oral Sedation: ASA I and ASA II

– IV Sedation: ASA I and and ASA II

• Dental Anesthesiologist or MD anesthesiologist

– General Anesthesia

• Unclear medical history from parents

• How well controlled are they?

– Asthma, Cardiac, Cancer, Sickle Cell Anemia,

Muscular dystrophy

– Airway

– Immunocompromised

– Post-operative issuesApril 9, 2018 Baylor College of Medicine 23

AntibioticProphylaxis• CardiacCondition• CompromisedImmunity• Shunts,Indwellingvascularcatheters,medicaldevices

• Prostheticjoints– nolongersupported


• DentalTreatment– Dentalproceduresthatinvolvemanipulationofgingivaltissueortheperiapicalregionoftheteethororalmucosa

– Possibleincreasedbacteremiaduringprocedure

– Extractions,scaling,invasivedentalprocedures


Cardiac Conditions

• Prosthetic cardiac valve or prosthetic material used for cardiac valve repair

• Previous infective endocarditis• Congenital Heart Disease (CHD)• Cardiac Transplantation recipients who

develop cardiac valvulopathy.


Congenital Heart Disease (CHD)

– Unrepaired cyanotic CHD, including palliative shunts and conduits.

– Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure

– Repaired CHD with residual defects at the site or adjacent to the site of prosthetic patch or prosthetic device


Compromised Immunity

• Immunosuppresionsecondaryto:– HIV– Severecombinedimmunodeficiency– Neutropenia– Cancerchemotherapy– Hematopoieticstemcellorsolidorgantransplantation

• SickleCellAnemia• Diabetes• Chronicsteroiduse


Shunts,Indwellingvascularcatheters,medicaldevices

• Nonvalvular devices, catheters, cardiovascular implantable electronic devices only at time of placement

• Shunts: – Vascular access

• ventriculoatrial, ventriculocardiac, and ventriculovenus shunts.

– Not ventriculoperiotoneal shunts



AHAGuidelinesforInfectiveEndocarditisProphylaxis:

Give30min-1hourpriortodentaltreatment.Amoxicillin50mg/kg,maximum2,000mgClindamycin20mg/kg,maximum600mg

• Patient requires antibiotic prophylaxis– Patient will be getting dental treatment in OR.

Should I prescribe them antibiotics prior?– Referring the patient to your office for

consultation because they have cavities. Should I prescribe them antibiotics prior?


LaboratoryValues• AbsoluteNeutrophilCountsandImmunocompromised– >2000antibioticprophylaxisnotnecessary– 1,000-2,000:Clinicaljudgement– <1,000:Antibioticnecessary– <500:Emergenttreatmentneeds.

• Plateletsandbleedingrisk– >75,000– 40,000-75,000Increasedbleeding,possibletransfusionneeded

– <40,000Transfusionneeded,Emergenttreatmentonly



Dental Emergencies

• Active Dental Infection• Dental Trauma


DentalTreatmentNeeds

• EmergentDentalNeeds– ActiveDentalInfection– ChronicDentalInfection


Localized Dental Infections

• Fistulas vs. Localized swelling– Fistula: “Pimple” appearance, flattened area where

purulent exudate is draining.– Long standing condition, most likely will require

extraction/Root canal therapy

Localized Dental Infections

• Localized Swelling– Long standing dental caries– Swelling may be sudden onset– Treatment, oral antibiotics to reduce swelling

so dental treatment may be completed– Decrease swelling so local anesthetic can be

placed

Cellulitis

• Swelling• Facial Pain• Eating and drinking• Fever• Malaise• Trismus?• Airway Compromise

Admitting patients: signs of sepsis (fever, lymphadenopathy, elevated WBCs), poor oral intake, doubt of homecare, need for operation, failure of outpatient management to resolve infection

Erythema, right at midline, unilateral

Trismus, Limited opening

EmergentDentalNeedsAirwayConcerns


§ Antibiotics § IV Antibiotics vs I&D

§ Pen VK, Clindamycin, Unasyn§ May require admission § Removal of source of infection§ Surgical intervention§ Active infection, difficulty with local

anesthesia

Orofacial Trauma

• Assessment• Dental Effects• Soft Tissue• Hard Tissue

Orofacial Injury Assessment

• Review health history• Assess

systemic/neurological effects

• Evaluate tetanus immunization

• Be alert to potential child abuse

(Cameron, Angus C.. Handbook of Pediatric Dentistry, 2nd Edition. C.V. Mosby, 2003.)

Tetanus

Clinical Examination

• Facial and neck palpation

• Intraoral examination• Primary site• Knee to knee position.

– Under the age of 3 years old

• Parents help stabilize the patient

Opening the Mouth

(Pinkham, Jimmy R.. Pediatric Dentistry: Infancy Through Adolescence, 4th Edition. Mosby, 04/08/2005.)

Orofacial Trauma

• Injuries to primary and permanent dentition

• Distinguishing between primary and permanent– Dental history

• Ask Parents

– Age of Patient• Permanent Central

Incisors erupt around 6 yrs of age

– Size of Teeth• Primary teeth: smaller

Injury to Primary Dentition• Greatest incidence of trauma to primary dentition

occurs at 2-3 years of age• Possible damage to permanent teeth

(Cameron, Angus C.. Handbook of Pediatric Dentistry, 2nd Edition. C.V. Mosby, 2003.)

Injuries to Permanent Dentition

• 6 years of age and up

Avulsed Permanent Tooth

• Reimplant• Reposition, xray,

splint, root canal treatment

Do not scrub clean

§ Ideal reimplantation within 60 minutes

§ If not re-implanted, transport to dentist § Viaspan§ Hank’s Balanced Salt

Solution§ Cold Milk§ Saliva § Physiologic saline§ Water

Bloody Tooth

Wet Tooth

Steps for you to take initially

• Transport medium• Antibiotics• Chlorhexidine rinse• Tetanus Vaccination

Follow-Up Care

Regular private pediatric dentistGreater Houston Dental Society: after hours

directory281-540-9393Operator sorts dentist by zip code

TCH Affiliated Dentistshttp://www.texaschildrens.org/Locate/Find-a-Doctor/ Under Dental Specialty Tab~30 private pediatric dentist

Soft Tissue Injuries

• Where are the fragments?• On the ground• Imbedded in surrounding soft tissues

such as the tongue, lip, or cheeks• Ingestion• Aspiration

Soft Tissue Injuries

.

•Hydration•Popsicles, cold liquids, and milkshakes•Avoid acidic and spicy juices or foods

•Infection is extremely rare in cases of these self-inflicted wounds •Usually antibiotics are not necessary

•Use vitamin E oil if you desire to coat the surface •Do not use Vaseline or petroleum jelly type

NewDevelopments

• SilverDiamineFluoride– Kills pathogenic organisms– Hardens softened dentin making it more acid

and abrasion resistant– Does not stain sound dentin or enamel– Stabilize caries on uncooperative child


Silverdiaminefluoride– Contraindications:Allergytosilver– Maystainmucosaifcontacted– Patient’shomeoralhealthhabitsneedtochange.


TCH Dental Clinic• Medical Compromised

– Patients needing dental treatment prior to:• Transplants• Cardiac surgery• Chemotherapy• Radiation treatment

• Special Needs Clinic– Autistic– Down’s – Cerebral Palsy – Cleft Lip and Palate

HelpfulWebsites

PreventionofInfectiveEndocarditisbyAHAhttps://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_307684.pdf

American Academy of Pediatric Dentistryhttp://www.aapd.org/policies/

Thankyouforyourtimeandattention


https://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_307684.pdf

http://www.aapd.org/policies/

• Questions?


Documents

Esther Yang, DDS April 7, 2018