Chapter 4: Pediatric Dentistry Introduction



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Nitrous Oxide/Oxygen Inhalation Sedation

Introduction


Nitrous oxide/oxygen inhalation sedation is a safe and effective behavior management technique.

Indications


Use of nitrous oxide/oxygen is indicated in the following situations:

Contraindications


Use of nitrous oxide/oxygen may be contraindicated in children who have medical conditions such as:

Concerns


You should consider the following factors prior to using nitrous oxide/oxygen inhalation sedation:

  • Precautions to reduce environmental exposure to the staff are required.

  • IHS guidelines require specific training and privileging.

  • Indications consent, flow rates, and duration must be documented

  • Facility requirements most often supersede IHS guidelines

Physical Restraint

Introduction


Physical restraint includes partial or complete immobilization with staff, parent, or devices to protect the patient and staff from injury during dental treatment. The use of restraints may be offensive to uninformed parents.

Indications


Use of restraint may be indicated in the following situations:

  • a patient who requires diagnosis/treatment and cannot cooperate due to a lack of maturity or a handicapping condition

  • when the safety of the patient or staff would be at risk without restraint

  • as a part of treatment during conscious sedation procedures

Contraindications


Use of restraint may be contraindicated in the following circumstances:

  • you are unable to receive written, informed parental consent

  • the child is cooperative

  • the child has a complicating physical or mental condition

Concerns


You must document the following information pertaining to the use of restraint:

  • indications for use

  • technique or device used

  • duration

Hand-Over-Mouth Technique

Introduction


The hand-over-mouth technique is a behavior management technique that is controversial and may be offensive to parents. A hand is placed over the child's mouth and behavioral expectations are explained. The hand is removed, or reapplied, depending on the behavior of the patient. Because this technique involves potential legal liabilities, its use is discouraged for other than senior clinicians and pediatric dental consultants.

Indications


Use of the hand-over-mouth technique is indicated for a healthy child who is able to understand and cooperate but who exhibits defiant or hysterical avoidance behavior.

Contraindications


Use of the hand-over-mouth technique is contraindicated in children if--

  • the technique causes occlusion of the nasal passages and restricts breathing

  • you are unable to obtain written informed parental consent.

  • the child is unable to understand and cooperate due to age, disability, or medication

Concerns


You should consider the following factors prior to using the hand-over-mouth technique:

  • Informed consent and indications for use must be documented.

  • Specific training in the hand-over-mouth technique--either at dental school or an IHS approved Continuing Dental Education (CDE) course--should be obtained before using this technique.

Conscious Sedation

Introduction


Conscious sedation is a minimally-depressed level of consciousness that retains the patient’s ability to:

  • maintain an airway independently

  • respond to physical or verbal stimulation

Indications


Use of the conscious sedation technique is indicated for:

  • ASA I or II patients who are healthy at the time of the appointment

  • patients who cannot cooperate due to disability or immaturity

  • patients whose need for care is consistent with the risks of sedation and whose care can be completed in one or two appointments

Contraindications


Use of the conscious sedation technique is contraindicated if:

  • there are medical contraindications (ASA III to IV patients)

  • you cannot obtain written informed parental consent

  • the patient is cooperative with minimal needs

  • the staff/facility is inappropriate for sedation

Concerns


You should consider the following factors prior to using the conscious sedation technique:

  • Indications consent, duration, drugs used, and monitoring must be documented.

  • IHS guidelines require specific training (40 hours minimum) and local clinical privileging. Please review guidelines.

  • Local facility guidelines supersede IHS policy.

General Anesthesia

Introduction


General anesthesia is a controlled state of unconsciousness accompanied by a loss of protective reflexes. The need for care must take into account the risks associated with general anesthesia.

Indications


Use of general anesthesia is indicated for:

  • patients with compromising physical or mental condition

  • the extremely uncooperative child with dental needs that cannot be deferred

  • patients with dental needs who otherwise would not obtain care

Contraindications


Use of general anesthesia is contraindicated if:

  • the patient is healthy and cooperative with minimal dental needs

  • you cannot obtain written, informed consent

  • there are medical contraindications to general anesthesia

Concerns


You should consider the following factors prior to using general anesthesia:

  • Clinical privileging is required (usually involving postgraduate training with anesthesia rotation).

  • The indications for and informed consent for the use of general anesthesia must be documented.

  • General anesthesia should not be attempted without medical consultation, in an inadequate facility, or without provision for recovery.

Practical Tips in the Behavior Management of Children


The following tips may be helpful when working with children:

  • Spend time with the parents to address their concerns and gain their trust.

You may need to define the parent’s role for treatment done in their presence.

  • Use appropriate vocabulary with the child to explain the instrumentation, what you will be doing, and why he needs to help.

  • Give the child a few simple, clear, non-threatening expectations so the child understands his/her role in the appointment.

  • Do not ask a question if it is possible that you will not like the answer. Instead of asking "Will you help me?" say "I need your help!"

  • Use distraction frequently. Children's active imagination will allow you to distract them with stories about animals, cartoons, or current movies. When you stop talking, the child will focus on what you are doing in the mouth.

  • Dental Assistants may need additional training to treat children well.

  • Units should be fully stocked. The child should never be left alone in the unit. Delays should be minimized.

  • Praise good behavior and reward if possible. Praise in front of parents works well. Give the child expectations for the next visit.

  • Never belittle a child or compare his/her negative behavior to another child’s good behavior.

  • Know when to try another approach, including referral.

  • Learn to work quickly; children often have limits to their cooperative ability.
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