UofL Dental Gift



Ped Competencies:4 sealants2 pt comp exams1 class II primary molar (amalgam or composite)1 SSC primary molar1 nitrous sedation1 diagnosis, tx plan &/refer space management 1 experience with special needsExamination of the Mouth and other Relevant StructuresProfessional Oral Health Intervention Periodicity depends on needs & risk factorsAnticipatory guidance and counseling 1st exam @ eruption 1st tooth; build “dental home”Components of Comp ExamGeneral health/growthPainExtraoral soft tissueTMJIntraoral soft tissueOral hygiene and perioIntraoral hard tissueDeveloping occlusionCaries riskBehavior PostureThe further forward the child leans his head, the more weight he bearsHead forward – compression of nerves in neck and spineNormal: 4-9 mmMusclesMm involved in breathingMm involved in masticatory systemMm of the neckMm of the back (sup and inf)Range of movement – cervicalMasseterElevates (closes) mandibleTemporalis Both ant and post together Eeevates mandibleAnterior portion protrudesPosterior portion moves jaw back (retrusion)Temporal tendonLateral pterygoidSuperior – retrusion and ipsilateral movement, openingInferior – opening (ONLY one that does this, protrusion, contralateral jaw movementMedial pterygoidElevates and moves mandible forwardSternocleidomastoid Unilateral – rotate head to opposite sideBilateral elevated headTrapeziusElevates, depresses, rotate, reflects shoulder bladeExtraoral ExamCentric RelationAdequate positionReslaxed musclesIndependent from the teethPure rotationsPosition can be repeatedReduction, “Clicking”On opening, an early click is ok, late click is badOn closing, an early click is bad, late click is okIntraoral ExaminationCentric OcclusionPrimary Dentition (Flush, M Step, D Step)Distal Step – 10%Flush terminal plane – 30%Mesial Step – 60%Baume’s 3 factors for Class I adjustment Mesial growth of mandibleEarly mesial shift-closure of generalized posterior spacing with eruption of 1st permanent molarsLate mesial shift drift of mandibular 1st perm molars into leeway spaceDental Arch/Occlusal Development from Infant to AdolescentClass I (61.6%), Class II (34.3%), Class III (4.1%)Distal step Class IIFlush Terminal plane Class I (56%), Class II (44%)Mesial step Class I (mostly), Class IIExcessive M step Class IIICentric Occlusion – see page 11/12 for photosPrimary dentitionOverbite:Normal = 10-40%19% - ideal27% - reduced24% - openbite20% - excessiveOverjetIdeal = 0-4 mm28% - ideal72% - excessiveMoorrees Longitudinal StudyStudies degree of overbite and how this changes as patient gets older.. there is no clear pattern (pg 12)Available Space-Incisor SegmentOn average 1.6 mm less space available for the permanent mandibular incisors than would be needed for ideal alignmentPrimary Dentition: SpacingPrimate spacing (Max: D to laterals, Man: D to canines)Baume: closes with early M shiftClinch: closes with eruption and drift of lateral incisorsGeneralized spacingLeighton study:Incisor Liability (Moyne)Ideal Primary Dentition OcclusionM step molars and caninesGeneralized and primate spacing2 mm overjet2 mm overbite (30%)“Ugly Duckling Stage” – when the canines are erupting, tend to flare laterals in the process (temporary)Factors affecting approach to incisor liabilityTeeth sizeSpacing primary dentitionIntercanine width growthArchlength increase due to more labial positioning of permanent incisorsSize differential b/w primary molars and premolars (leeway space)Summary of Arch changesMaxillaSlight increase in archlength due to labial position of incisors and increased intercanine widthMandibleLoss of posterior archlength due to space closure (generalized and “E” space)Slight increase in anterior archlength due to labial position of incisors and increased intercanine widthAirwaysNose breathers can become mouth breathersThis change can have big consequences Facial changes – pg 16RadiographsShould I take X-Rays?Timing of initial radiographic exam should not be based upon the patient’s age, but upon each child’s individual circumstancesRx should be taken only when there is an expection that the diagnostic yield will affect pt careTypes:PA, BW, Occlusals, Pan, lateral/frontal ceph, othersInitial ExamPrimary dentitionBW, if no direct viewMix DentitionBW and panPermanent4 BWRecall PtDMF or High risk ptBWPrimary & mix dentition every 6 months or until no evidence of cariesPermanent every 6-12 monthsNo DMF or low risk ptBWPrimary & mix every 12-24 monthsPermanent every 18or 24 monthsPeriodontal dsComplete series of PA’s and BW’sPrecautionsEvery precaution should be taken to minimize radiation exposure, protective thyroid collars and aprons should be used whenever possible. This practice is strongly recommended for children, women of childbearing age, and pregnant women.TREATMENT PLANNINGReview Standard of care recommendationsRisk assessmentOngoing risk assessmentCRA form/CAT toolDiagnostic codesRisk assessment CODES (pg 20)Biofilm and biomarkersHow to monitor cariesDiagnodent – to check remineralization – NOT TO TWEarly diagnosis 500 microns deminDO BACTERIAL COUNT at 6 months ageISOLATIONRubber dam, punch one big hole, stretch over ~4 teethRestorative MaterialsComposites, amalgams, cements, veneers, crowns, pediatric crownsHigh vs Low speedNo literature that proves high better than lowHigh speed best for enamelLow speed for dentin (low speed can break enamel structure)Indirect pulp cap better than removing all decay and exposing pulpW/ water vs W/o waterBetter with waterIsolation vs no isolationAlways use, except in sealants sometimes to avoid anesthesiaBottle vs unidoseNo significant difference Carbide vs diamondDiamond better for enamel (also for dentin, but need to acid etch for more timeCarbide - cuteSmear Layer ADDIN AudioMarker 755 after you cut/remove decay you are worign on smear layer in dentin ADDIN AudioMarker 768 want to expose dentin tubules and leave good dentin to place good bonding material and add good composite ADDIN AudioMarker 893 leave dentin damp when placing bonding agent ADDIN AudioMarker 908 If completely dry and dehydrated, bonding wont work b/c dentin will try and get wet.. so leave it damp for retention ADDIN AudioMarker 1046 bonding agents are hydrophilic Conditioner and Acid Etch1. Redford 198610% phosphoric acid 15 seconds (primary dentition – 7-10 sec)Primer (methacrylate)Dehydrating agentsAldehydeAcetoneAlcoholBonding agents – pg 25Technique sensitiveRestorative materials “esthetic color”Silicate cementsGI cements CompomersRMGIComposites (resin // “strip crowns”)SSC – modifiedZirconia crownsPg 27CompomerDyract(L.D. Caulk/Dentsply)CompoglassVivadent/IvoclarHytacESPEFillerResinsFlowable Composites – less fillerEliminate Myths//DOGMAS…Restorative materialsAmalgamApproved for primary dentition (2 surface class II, Class I & V) and permanent (class I, II, V)Predictions: Mean survival timeAmalgam vs CompositeRecall appts every 6 months for 5 years267 (6-10 years) amalgam vs compomers in primary teeth6% compomers replaced (recurrent caries)0.5% amalgams were replaced (recurrent caries)statistical significance267 (6-10 years) amalgams vs composites permanent teeth12% composites replaced (recurrent caries)11% amalgams replaced (recurrent caires)no statistical significance composites as good as amalgamwear 50 microns a yearwear 250 microns over 5 yearshalogen light-silorane decrease shrinkage to 1%Amalgams vs HealthDalen, 2003 – no correlation detected b/w memory and exposure to amalgamHujoel, 2005 – no evidence that amalgam placed during pregnancy increased low-birth-weight riskBellinger, 2007 – no evidence that amalgam produced adverse neuropsychological effects over 5 yearsLauterbach, 2008 – amalgam did not affect neurological status of childrenRoberts, 2008 – no change in resistance to mercury or antibiotics in children with or without amalgam fillingsPulp TherapyPulp FactsAnatomical Differences Primary pulps largerPrimary root canals are smallerPrimary molar roots have more variable anatomy Primary teeth predisposed to internal resorptionOptionsPulp therapy for the primary dentition includes a variety of options, depending on the vitality of the pulpDifficult if not impossible to determine clinicallyt the histology of the pukpWe attempt to do this by using clinical & rx infoPulp Therapy in Primary and young Perm TeethPain assessment Further Clinical AssessmentExtent of lesion location, colorMobility rule out root resorptionSoft tissue swellingLymphadenopathySensitivity to percussion reliable in primary teethPulp exposure hemorrhagic vs necroticPulp testing electrical, thermal, percussionRedness, selling, gross caries, missing/fractured restoration, carious marginal breakdown, draining parulis, fluctuation felt by palpation, mobility, thermal and electrical vitality testsReliability of Pulp Testing No Single Diagnostic Test is Reliable TeethPrimaryYoung PermanentMature PermanentElectrical-++Thermal++++Percussion++++Radiographic Criteria for Healthy PulpAdequate periodontal support No decalcified lesions or root fracturesNo internal/external resorption or radiolucency Radiographic AssessmentAccessory canals, no vital pulp tissue w/interradicular bone loss77.5% mandibular primary molars had accessory canals in floor of chamberOperative DiagnosisDirect evaluation pulp tissueNature of the bleedingRed color & hemostasis in less than 4 minutes indicates radicular vitalityPersistant bleeding indicates infections has reached radicular pulpVital Pulp TherapyProtective base/linerIndirect pulp treatment (IPT)Direct pulp capping (DPC)PulpotomyPharmacotherapeuticNon-pharmacotherapeuticPartial pulpotomy (permanent teeth)Protective base/linerIndications (AAPD):Normal pulpPreparation in dentinAll caries removedObjectivesPreserve pulpal vitalityMinimize microleakage/sensitivity Indirect Pulp Treatment (IPT)IndicationsDeep carious lesionsReversible pulpitisIncomplete caries removalNo pulp exposurePulp vitalObjectivesComplete seal, preserve vitality, no post-treatment symptoms, no harm to succedaneous teeth, continued root development in permanent teethIPT (indirect pulp treatment) Technique Apply medicament/material over carious or sound dentin [Ca(OH)2 most commonly used]Vitality should be preserved If planning to re-enter, wait 6-8 weeks for tertiary dentin; removed remaining caries, restore; eliminate microleakageNeed to re-enter controversialRadiolucency beneath IPT decreased in size or did not increase under Dycal/ZOE in majority of casesSuccess rate up to 90%Recent Data:IPT (GIC) had higher success rate than FMC pulpotomies IPT (Ca[OH]2) success rate in primary molars was 95% in retrospective studyCarious dentin undergoes mineral gain when sealed in IPTDeep CariesThin dentin over pulpTubules are large in diameter and packed close togetherDentin is extremely permeable Caulk Dycal, Reinforced CaOHVital Pulp TherapyProtective base/linerIndirect pulp treatment (IPT) Direct pulp capping (DPC)PulpotomyPharmacotherapeuticNon-pharmacotherapeuticPartial pulpotomy (permanent teeth)Direct Pulp CapIndicationsSmall mechanical or traumatic exposure in primary teeth with normal pulpSmall carious or mechanical exposure in permanent teeth with normal pulpContraindicated for carious exposure in primary teethObjectives:Preserve vitalityNo post-tx signssymptomsPulp healingTertiary dentinNo pathologic changesNo harm to successorsContinued root formation for perm teethPulp Capping AgentsMineral trioxide aggregate (MTA)Ca(OH)2 still widely used and taightZOE – chronic inflammationTotal etch techniqueDirect Pulp Cap – BleedingSuccess inversely related to bleeding at siteDebris @ exposure site: clean out with saline or anesthetic to prevent inflammation; keep pulp moistClot will prevent contact of material with the pupSuccess rate up to 80-90% when bleeding is well controlledDirect Pulp CappingEven in these cases success rates are not particularly highFailure results in internal resorption or acute dentoalveolar abscessDirect pulp cap success rate on primary teeth is not as great as pulpotomy Partial Pulpotomy – CriteriaNo pain or recent pain of short durationNo swelling, mobility, reaction to percussionNo internal/external resorption, changes in PDL, radiographic abnormalitiesPulp exposure 1-2 mm, bleeding stops <1-2 minInflammation, infection superficial onlyOnly superficial pulp removedPartial Pulpotomy TechniqueEnlarge exposure, removing exposed pulp tissuePlace capping materalPlace leak-proof sealZOE covered with GIC or calcium hydroxide of resin composite is to be usedOBJECTIVESRemaining pulp stays vitalNo adverse clinical signs/symptomsContinued apexogenesis in immature teethAdvantagesRemoves inflamed, infected portion of pulpPreserves cell-rich coronal pulpFacilitates washing away carious debrisAllows better contact with more materialIncreases healing potentialPhysiological apposition of cervical dentinNo need for root canal therapyNatural color/translucency preserved Pulpotomy for Primary TeethIndications:Deep lesion adjacent to pulp that is normal or reversibly inflamed, orPulp exposed by traumaCoronal tissue can be amputatedRemaining radicular tissue vital (clinically and radiographically)ObjectivesPreserve vitality of radicular pulpNo adverse signs or symptomsNo radiographic pathology No harm to succedaneous teethTechniquePrepare tooth for restoration (typically SSC)Excavate carious dentin, unroof pulp chamberAmputate coronal pulpHemostasis (diagnostic value)Treat remaining pulp (medicament/energy)Seal and restoreClinical indicationsMechanical/carious exposure, traumaInflammation limited to coronal pulpAbsence of spontaneous painAbsence of swelling or alveolar abscess formationRestorable toothContraindicationsPresence of fistula or swellingEvidence of necrotic pulpUncontrolled pulpal hemorrhagePeriapical or bifurcation radiolucencyPathologic resorptionDystrophic calcificationMore than 1/3 root resorptionCategories of MedicamentsFixativesFMC, gluteraldehydeMineralizing and/or bacteriostatic agents Ca(OH)2Palliative sealersZOEObturatorsMineral trioxide aggregate (MTA)Coagulants Iodoform, Ca(OH)2Antibiotics/AntimicrobialsErythromycin, othersPulpotomyThe radicular pulp is healthy or is capable of healing after surgical amputation od the affected or infected coronal pulpPresence of any signs or symptoms of inflammation extending beyond the coronal pulp is a contraindicationContraindications:Swelling of pulpal originFistulaPathologic mobilityPathologic external root resorptionInternal root resorptionPeriapical or interradicular radioleucencyPulp calcificationsExcessive bleeding from amputated radicular stumpsHx of spontaneous or nocturnal painPain or tenderness to percussion or palpitationFormocresol Pulpotomy TechniqueLA and rubber damRemove superficial cariesRemove roof of the pulp chamberAmputate the coronal pulpSharp spoon excavator#4 round bur in slow speedbeware of perforating pulpal floordon’t leave tags of tissue under ledges of dentinPlace moist cotton pellets to obtain hemostasis (apply pressure)Upon removal pellet, hemostasis should be apparent, minor bleeding may be evidentFormocresol blotted pellet = Buckley’s solution – 1/5 dilutionFollowing hemostasis place formocresol pellet for 5 minWhen removed, site will appear dark brown or dark redRemove pellet and cover floor of chamber with ZOE Caulk 2200Lightly condenseFill access with alloy if temporizing or place SSC same appointmentMost authorities now agree that formocresol is at least potentially immunogenic and mutagenic. For these reasons, efforts have increased to find a substitute medicament.Potential Substitutes for FormocresolZOEGlutaraldehyde (GA)Ferric SulfateSODIUM HYPOCHLORIDEElectocauteryLaserNo long-term controlled clinical studies are available to elevate their successFerric SulfateHemostatic agentClinical studies promisingFuks et al reported 93% success rate vs. 84% success rate for formocresol at 36 monthsStudies on formocresol pulpotomy of primary teeth and the occurance of enamel defects on the permanent successor have found no effectPulppotomy FailureIncreased mobility, fistulous tractPremature exfoliationRx evidence of interradicular/periapical radiolucencyInternal/external resorptionCaused by poor diagnosis and tx selectionRadical Treatment (Non-Vital)Pulpectomy and Root FillingIndicated on teeth that show evidence of chronic inflammation or necrosis in the radicular pulpIdeal IndicationIs a case of pulp destruction of a primary second molar that occurs before the eruption of the permanent first molar, thus avoiding a distal shoe space maintainerPulpectomy ContraindicationsTooth not restorableAdvanced internal or external resorptionLess than 2/3 of the primary root structure remainingPeriapical infection involving the crypt of the succedaneous toothRoot Canal Filling MaterialsZOEIodoform Paste (KRI)Calcium Hydroxide (Vitapex)Must be resorbablePulpectomy TechniqueAccess similar to pulpotomy, but walls flared moreLocated canal orifice of the rootsUse broach to remove as much organic material as possibleEndo files are selected and adjusted to stop 2 mm short of rx apex of each canalUse files w/ sodium hypochlorite irrigation to remove as much organic as possibleDry canals with paper pointsFill canals using thin mixture of ZOE (w/o accelerators) using plunger technique or pressure syringeSTAINLESS STEEL CROWNSRandall, 2000% failure SSC: 1.9% - 30.3%% failures amalgams: 11.6% - 88.7%AMALGAM:SSC FAILURE RATE 9:1Ines, 2007 COCHRANENone of the studies accomplished the inclusion criteriaThat doesn’t mean that SSC are not effective, although we need more infoMesser and Levering, 1988 General Success 88%; less success on teeth tx with pulpotomiesMTA vs Ca(OH)2 ApexificationEl Meligy and Avery 2006Necrotic permanent teeth requiring root-end closure15 received MTA15 received Ca(OH)2Recalled at 3, 6, and 12 months2 Ca(OH)2 failures at 6 and 12 monthspersistent periradicular inflammationNO MTA failurePulpal Revascularization of Immature Necrotic Permanent TeethAssumption:Apical portion of pulp may still be vitalGoal: encourage vital tissue to migrate coronallyProcedure:Disinfect root canalPlace triple antibiotic paste (ciprofloxacin, metronidazole, cefaclor)Remove paste after several weeksInduce bleeding by stimulating tissue beyond apexAllow clot to reach CEJCover with MTA, restoreResulting clot acts as scaffold to aid growth of new tissue in canalExpect continued root lengthening and thickening, pulp responsive to cold stimulusRADIOGRAPHSShould I take X-Rays?Timing of initial rx exam should not be based on age, but upon each child’s individual circumstancesRx should be taken only when there is an expectation that the diagnostic yield will affect patient careSealantsHeller 1995 (5 years)Sound (NO CARIES)NO SEALANT – 13% cariesYES SEALANT – 8% cariesIncipient Caries or in doubtNO SEALANT – 52% cariesYES SEALANT – 11% cariesSealants:Autocure, photocure (resins with or w/o filler)Change of colorAutoetch/acid eitch/air abrasionFluoride deliverySealants:Fissurotmy – enameloplasty with high (preferred due to microfractures from slow speed)/low speed with diamond/carbideHigh speed vs slow speedDiamond vs carbideLaser – can do more conservative txAir abrasionSealant procedure:ProphyRoughen surface with pumice (w/o fluoride)Rinse, etch 15, rinseDry, bond, cure 15 secSealants, cureSealants: If done correctly, can last a very long time, do not have to use a rubber dam, can use cotton rollDental Materials – acid etchRedford 198610% AF10% PHOSPHORIC ACID 15 secsDeferred Treatmentrisks/benefits mist be explainedART/Interim Therapeutic Restoration and regimented application of fluoride varnishAdvanced Behavior GuidanceProtective stabilizationSedationGeneral anesthesiaBasic Behavior GuidanceCommunicativeDistractionTell-show-doNonverbalPositive reinforcementVoice controlparental presence/absencenitrous oxide - considered as a basic behavior guidance, when anxiolytic/analgesic levels are usedNitrous OxideInhalationalMechanism: gas is absorbed rapidly (2-3) minutesFrom alveolir and is held in solution in the serum for distribution into tissues and cells of CNSEffects: Anxiolysis/AnalgesiaAnxiolytic effectActivation of the GABAA receptor through the benzodiazepine binding siteAnalgesic effectInitiated by neuron release of endogenour opiod peptidesActivation of poiod receptors, GABAA, noradrenergic pathwaysMild CNS depressionMaintenance of blood pressureOnly minor depression of cardiac output w/slight increase on peripheral resistancePre-procedural Considerations NOEquipmentAppropriately fitting nasal hoodMust be capable of delivering 100% and never less than 30% O2 – fail/safe mechanismDoes not allow nitrous to flow w/o O2Fail-safe mechanism checked and calibrated regularly (document calibration)Must have scavenging systemEmergency cartPositive pressure O2 delivery systemE cylinder, capable of delivering 90% O2 at 10L/min for 60 minutesSelf-inflating bag-valve-mask device which delivers 15L/minPersonnell and trainingMust be administered by licensed individualsPersonnel must have appropriate training and certification in CPRPeriodic reviews of office emergency protocolAdministration of NOMust be administered by licensed individuals Flow Rate of 5-6 L/min100% O2 for 1st 1-2 mintitrate nitrous oxide to max 50%continue with communicative techniques, pt become highly suggestiblecan titrate dose down at subsequent visits, large placebo effectnausea increased by longer administration NOHigher conc NOIf child appears restlessMay be ready to vomitMay be entering deeper level of sedationUse lowest level of NO that produces desired responseClinical observation of pt b4, during, assessed by spoken responses to commandsIf other pharmacologic agent is used (other than LA) use monitoring consistent with that required for appropriate level of sedationUse NO > 60% may cause moderate to deep sedation100% O2 for 3-5 min after discontinuing nitrousdocumentpercent NO usedduration procedurepost-tx oxygenationpt response to NONitrous advantagesRapid onset and recovery timeEase of titration – especially in a calm ptLack of serious side effects – excellent safely recordCan be used with communicative behavior guidance techniquesDentist’s behavior major influenceCommunicative techniques more effective with nitrous oxideNitrous DisadvantagesWeak agentDepends on patient acceptancePatient must be able to breath through noseOccupational hazardsMay increase risk of miscarriage greater in dental personnel with prolonged exposure AND no scavenging systemMay potentiate effects of other sedatives to a dangerous degreeIn high doses may cause nausea or excitement1-10% patientsdiffusion hypoxia may occur if insufficient oxygenation at end of procedure; rapid release of NO from blood stream into alveoli, diluting concentration of oxygenheadache, disorientationNitrous Oxide InidcationsMild to moderate fear Certain mentally, physically, medically compromised patientsPatietns with exaggerated gag reflexCooperatiec patient undergoing a lengthy dental procedurePt with difficult achieving local anesthesia ContraindicationsCOPDCaution – medical consult indicatedAcute ostitis mediaSevere asthmaSickle cell disease – has been shown to cause neuropathyBleomycin sulfate therapy (anti-neoplastic antibiotic) – oxygen administration can lead to interstitial pneumonitis which can be fatalNitrous oxide used with other pharmacologic agentsIncreases sedative effect – deepens level of sedationChloral hydrate – also increases respiratory depression effectDiazepamMidazolamAdvanced Behavior GuidanceDocumentationType of stabilization used and whyLength of time stabilization used for patientEffectiveness stabilizationLevels of sedationPt can move from one level to another w/o warningDefined by pt responsiveness and physiologic changesMonitoring requirements increase as level of sedation increases MonitoringClinical level of consciousnessResponsivenessConversationBody movementEyes open or closedMonitors during sedationObservation of patientPulse oximeterCapnographPre-cordial stethoscopeBPEKGTempConsiderations for SedationFamiliarity with current guildlines for sedation: State Boards of Medicine and Dentistry are the ultimate determinantsCareful patient selectionChoose type of drug based on type/legth of procedureSelect lowest does of drug with highest therapeutic index for the procedureKnowledge about drugs being usedTime of onsetPeak response timeDuration of actionInformed consent Pre-op instructions, including dietClear liquids – up 2p 2 hrs pre-opBreast milk – 4Infant formula – 6Non-human milk – 6Light solid food – 6Responsible person must be available for transport of pt – preferably 2 individulasMonitoring appropriate to level of sedation, based on guildinesEmergency preparednedd, including EMS back upDocumentation – pre-op, during, and post-opSedation – Patient SelectionASA I & II – generally appropriate for sedationASA III & IV, special needs, airway abnormalities, increased tonsil size – get consults as indicated; sedation may be contraindicated in these patients. Consider for possible GA where airway, medical condition can be best monitoredPt assessmentMed hx – birth to present Any current illnessChronic conditionsPhysical assessmentCardiovascularRespiratory: airway development and healthWheezing is common in kids 0-3 yrsWheezing related to hx of resp syncytial virus (RSV) in infancy30% pt with RSV hx in infancy have recurrent lower respiratory infections or wheezing 6-8 yrs after initial infectionSedation – tonsil sizeBrodsky Scale 0 to +40 means tonsil is in the fossa+1 means less than 25% obstruction +2 less than 50%+3 less than 75%+4 is more than 75% obstruction Patient selection – sedationMallampati classification – size of airwayClass I – visualization of soft palate, fauces, uvula, anterior and posterior Class II – visualization of soft palate, fauces and uvula Class III – visualization of soft palate and base of uvulaClass IV – soft palate not visibleSnoringGag reflexCurrent medication, including herbalSome medications can increase duration of action of sedative medicationsBehavior assessmentPoor candidate for sedation:Sleep apneaObesity – greater risk for aspiration, especially with BMI of 85th percent of higherIncreased neck circumference – associated with adverse respiratory eventsAbnormal airway – tongue, tonsilsIn sedated children with large tonsils, head rolling forward causes significant airway obstructionChronic conditionsModerate to sever asthmaLiver or renal diseasePoorly controlled seizuresPatients at risk for aspiration: CP, GERDSedation: Child’s airway is challenging Diferent anatomy increases risk of airway problemsNarrow trachea, narrow glottis, narrow nasal passagesRelatively larger tongue/epiglottisMandible less developedIncreased airway resistanceMonitoring airwayHead airwaySnoringPatient colorChest movementUse rubber dam to protectSedation-Respiratory SystemVentilation: air movement into/out of lungsHigher respiratory rate in childrenSmaller tidal volume in childrenOxygenation: oxygen delivered to tissue (brain)Requires patient airwayTransport across alveoliHb transport of O2Transport via cardiovascular systemMetabolic tissue exchange: oxygen-carbon dioxideElimination of carbon dioxideCardiovascular SystemHeart rateNormal: 4 yr old – 100 beats/minNormal: 10 yrs – 90 beats/minChild’s blood pressure totally dependent on heart rateDrop in bl pressure totally dependent on heart rateDrop in heart rate leads to hypotensionHypotension in a child signifies decreased heart rate and should be taken very seriouslyMonitoring cardiovascular eventsBlood pressureCuff should be 2/3 upper arm lengthToo small – high reading; too large – low readingPulse oximeterPulse palpitation – closest to heart is bestRoutes of administration – general considerationsOralMost common routeEasily accepted – no injectionsProlonged onset and recovery Relatively safe if using one drugUsing combinations of drugs increases risks of adverse outcomes – less predictable First past hepatic metabolism leads to low bioavailabilityInability to titrateIntranasalRapid onsetNasal mucosa links to CNSPlasma levels similar to IVUse atomizer: 1cc syringe? dose to titrateinability to titrateuse lower dose – no first-pass metabolismindicated for patient who refuses oral medspatients find administration unpleasantIntramuscularFaster absorption than oralEase of administration – no taste issuesPotential for trauma to injection siteProlongued onset and recoveryInability to titratePainfulIncreased liability costsIntravenousOptimum routeRapid onsetDrug can be titrated to achieve desired effectAbsorption not a factorDrug can be administered in small amounts over timeIV access is available in case of ermegencyDifficulty in starting IV in difficult/obese pateintsVenipuncture complications – hematomaRequires highest level of monitoringIncreases liability costsWhy nitrous oxide Fear of an unpleasant experience, namely painNO relieves both the physiological and psychological aspects of pain65% gen dentists and almost 90% ped dentists use NORationaleUse of inhalations sedation with NO and O has many significant advantages over methods of pharmacosedationLow lipid solubility – excellent ability to titrateNitrous Advantages:1. Onset of action – onset is more rapid than oral, recatal and IM. IV sedation is roughly equal2. peak clinical effect – peak clinical actions do not develop for most oral, rectal and IM drugs for a period of time that makes tritation absolutely impossible 3. Alteration of Depth of Sedationdepth of sedation achieved with inhalation sedation may be altered from moment to moment with no other sedation technique does the administrator have as much control over the clinical action of a drugdegree of control represents a significantly safelty feature of inhalation sedation4. Duration of Actionduration of action is an important consideration selection of sedation techniques5. Recovery Timerecovery time from inhalation sedation is rapid and is the most complete of any techniqueN2O is not metabolized by the body, the gas is rapidly and virtually completely eliminated from the body, w/in 3-5 minutes. In all other techniques the recovery form sedation is considerably slower6. Ability to Titratetitration is ability to administer small incremental doses of a drug until desired clinical action is obtained. Ability to titrate represents the greatest safety feature a technique can possesssignificant drug overdose will not develop in techniques in which titration is possible, as long as the practitioner titrates the drugs usedintravenous and inhalation sedation allow for titration. No other sedation technique is capable of titration7. Ability to Titratein the outpatient setting it is in everyone’s best interest that the pt is discharged from the office with no prohibitions on their activities.Drug administed for the reduction of fear and anxiety are CNS depressants. A patient must have an escort for a number of hours following administration of these drugsInhalation sedation recovery is almost always complete, a patient usualyy may be discharged from the office alone, w/no restrictions 8. safe, very few side effects9. N2O-O2 has no adverse effects on liver, kidneys, brain, or cardiovascular and respiratory system11/9 – Space ManagementKnow eruption pattern for primary & permanent dentitionOverjet perm: 2mmOverjet primary: 0-4mmOverbite for perm & primary: 2mmGrowth of mandible: upward, posterior, backwardGain 1mm on max & 2mm on mand (IDK what this means)Consider bruxism, airway, tongue habitsMost important: tongue pushes outward & lips & cheek push inwardAs soon as mand incisors erupt, if no space crowding; if space corrected w/ tongue pressureIntermolar width (b/t primary & perm) the sameCanine width will change b/c eruption of teeth faciallyBone is added in the back and resorbed in frontMaxilla stops growing @ 6 y/oMandible stops 14-16 +/- 4, boys up to 22can wait up to 22 to take out 3rd molarsMaxillaGrows faster for shorter pd time Anterior and 2° palate12-13 y/o 1 bonePost cross-bite b/t 6 &9 expansionMandiblefuses at one y/ogrows slower for longer pd of timePredicted WidthSum incisors/2 + 10.5 = predicted width mandSum incisors/2 + 11 = predicted width maxillarBand & Loop – ext first primary molarIf molar already erupted, don’t have to do anythingIf not in occlusion, band & loopCan’t do lingual lower holding arch if don’t have 4 perm incisorsBand & loop – if need to ext second primary molarDon’t have to place B&L if 2nd permanent molar eruptedDO if 2nd permanent molar not eruptedNovember 16 – Space management (contin) & oral habitsDistal shoe: Prevent “mesialization” of 1st permament molar when extraction of 2nd primary molar is needed When there is space, mandibular molars will “mesialize.” Maxillary molars rotateBand & LoopShorter on the buccal, longer on the lingual segmentWant canine to be able to “grow in”Don’t want to block premolar from eruptiongTPA – stop rotation of maxillary 1st molars to prevent space lossBands should be 1mm below marginal ridgeshould not be uncomfortable to gingivaif see ischemia, trim bandOral habits:as soon as detect, try to remove the habittry to induce pacifier, rather than finger harder and more harmfulremove habit before 3 y/o; after 3, can’t be corrected by removalduration > magnitude > frequencyACTIVE > passiveTongue should be on cingulum of anterior teeth when we swallow>36-48 mo – altered occlusionThumb- ant openbite & increased overjetPacifier: post crossbiteMouth breathers: ant openbite & post crossbite; send to ENT if airway issuesMay need to defer tx if too youngGloves, bluegrass appliance, crib, rake: 3-6 y/oBiting Lip habit: upper incisors flared out, lower inclined linguallyPull check in/sucking: ulcer on cheekV-shaped arch/deep palate: thumb-suckingGuidance, interception (appliance ASAP), active txTreatment: Simple: single tooth Compound: multiple teethComplex: skeletal discrepancyCompound & complex: dental & skeletal – may need to refer ................
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