Chapter 4: Pediatric Dentistry Introduction

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Child Abuse and Neglect


Although we often view the childhood years as a period of love and caring, for many children reality is starker. Child abuse and neglect (CAN) is a growing concern with more than 2,000,000 incidents reported yearly in the United States. Although CAN may be found in any socioeconomic group, family stress (e.g., unemployment, marital discord, or substance abuse) may be contributory.


The following definitions are used in describing CAN:

  • Child abuse is the harm or threatened harm occurring through non-accidental physical or emotional injury, suffered by a child through acts or omissions of a responsible caretaker.

  • Child neglect is the failure of a responsible caretaker to adequately provide food, shelter, clothing, or other care necessary for the child’s health and welfare when able to do so financially.

  • Dental neglect is the willful failure of a parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection.

Reporting Responsibility

Health professionals in all 50 states are required by law to report CAN or suspicion of CAN (SCAN). Proof is not required on the part of the reporter but is to be determined by child protective agencies. Failure to report CAN may result in civil or criminal penalties.

Suspicion, not proof, mandates all health care professionals to report CAN. If reports are made in good faith, the reporter is protected from prosecution. Policies in service units differ, but reports are usually made to the Social Services Department or the Child Protection Team. Check with your service unit administrative staff or clinical director for the reporting procedures at your facility.

Federal programs are covered under federal reporting guidelines in addition to state requirements.

Behavioral Signs in Diagnosing CAN

Child abuse results in physical damage as well as emotional scars. Behavioral signs may include:

  • inappropriate anxiety due to parental presence or absence

  • withdrawn behavior

  • avoidance of eye contact

  • overly vigilant behavior by the parents or guardians

Physical Signs in Diagnosing CAN

Physical signs of CAN may include:

  • burns

  • unexplained hair loss

  • lacerations

  • bruises that are shaped like a hand or object

  • bruising in different stages of healing

Clothing that is inappropriate for the season may be used to cover physical signs.

Oral Signs in Diagnosing CAN

Dental staff often are the first providers to observe CAN with 65 percent of all physical abuse involving orofacial injuries. Oral signs of abuse may include:

  • torn frenum(s)

  • intraoral lacerations

  • fractured, displaced, or missing teeth

Section D: Local Anesthesia in Pediatric Dentistry


Improper anesthetic technique probably creates more inappropriate behavior than any other single factor in pediatric dentistry. Many studies have demonstrated that a child's worst behavior occurs during the injection phase of restorative dentistry. Therefore, your primary goals should be to deliver the anesthetic with minimal discomfort and to achieve profound anesthesia.

Tips for Successful Local Anesthesia in Children

The following are suggestions to use when delivering anesthesia to children:

  • Use behavior management techniques (e.g., distraction, encouragement, or nitrous oxide).

  • Always use topical anesthetic; wait at least 60 seconds.

  • Use a short, 30-gauge needle.

  • Deliver the anesthetic slowly; rapid injection causes pain.

  • For most treatment, lidocaine 2 percent with epinephrine 1:100,000 or mepivacaine 2 percent with levonordefrin 1:20,000 are recommended.

Common Errors in Using Local Anesthesia

The most common mistakes made by dentists are:

  • failure to ascertain success of the injection before beginning treatment

  • over dosage

  • failure to deliver enough anesthetic to achieve anesthesia


Local anesthesia achieves toxic levels much more rapidly in children. To avoid local anesthetic complications, know your patient's weight and the maximum dose allowable for the drug you are using. Develop the habit of using only 1/2 carpule for each quadrant to avoid reaching the toxic level and still provide good anesthesia. The safe dosage for lidocaine and mepivacaine in children is 2 mg/lb. During conscious sedation procedures, dosages should be reduced by 50 percent.

Maximum Dosages

The following table provides dosages of 2 percent lidocaine with 1:100,000 epinephrine (or 2 percent mepivacaine with 1:20,000 levonordefrin*) for pediatric dental patients:

Maximum Dosages of 2% lidocaine with 1:100,000 epinephrine and

2% mepivacaine with 1:20,000 levonordefrin

Patient Weight (lbs.)

Maximum Dosage mg

No. of carpules



















* 3 percent mepivacaine contains 50 percent more drug per volume.
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