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CHAPTER 6
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K. Diagnosis andProblem List
Diagnosis
• Dental caries
Problem List
• No dental home
• Poor oral hygiene and cariogenic diet
• Caries risk assessment is high
BACKGROUND INFORMATION 1
Local Anesthesia Administration (Figure6.2.2)
• Discomfort of local anesthesia administration can
be lessened by:
Use of topical anesthetics: available in gels and
sprays
Counter irritation: application of vibratory
stimulation or moderate pressure at the site of
injection (Figure6.2.3)
L. Comprehensive Treatment Plan
• Dental caries requiring restoration using local
anesthesia (see Background Information 1 and
Fundamental Point 1)
• Implement aggressive prevention plan
• Recall visits every three months
Figure 6.2.2 Local anesthetic infiltration in maxillary
vestibule.
M. Prognosis andDiscussion
• Good prognosis for dental treatment since patient is
cooperative
• The patient has a guarded prognosis for future dental
caries due to poor oral hygiene and diet and the lack
of a dental home
• Establishment of a dental home and compliance with
a rigorous prevention plan would improve the
prognosis and caries risk assessment
• It is important to give very clear postoperative
instructions to the patient and parents. They must be
instructed to avoid any manipulation (chewing,
scratching, etc.) of the anesthetized tissue to avoid
self‐inflicted trauma (see Background Information 2)
Figure 6.2.3 Local anesthetic palatal infiltration. Mirror
handle is used as counter irritation.
Distraction: maintain constant communication to
keep attention away from syringe
Slow rate of administration: administration of a
cartridge of anesthetic should take at least one
minute
(Gosnell and Thikkurissy 2019)
FUNDAMENTAL POINT 1
Maximum Doses ofLocal Anesthetics
inChildren (American Academy ofPediatric
Dentistry [AAPD] 2018–2019)
• Articaine: 7.0 mg/kg, 3.2 mg/lb, 500 mg total
• Lidocaine: 4.4 mg/kg, 2.0 mg/lb, 300 mg total
• Mepivacaine: 4.4 mg/kg, 2.0 mg/lb, 300 mg total
• Prilocaine: 6.0 mg/kg, 2.7 mg/lb, 400 mg total
• Bupivacaine: 1.3 mg/kg, 0.6 mg/lb, 90 mg total
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BEHAVIOR GUIDANCE ANDMEDICAL EMERGENCIES
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N. Common Complications andAlternative
Treatment Plans
• What should you do if you reach the maximum
recommended amount of local anesthetic and the
child is still complaining of pain?
• What should you do if the child bites his lip or tongue
after receiving local anesthesia?
BACKGROUND INFORMATION 2
Local Anesthesia Complications
(AAPD2018–2019)
Paresthesia fromLocal Anesthesia
• Defined as persistent anesthesia beyond the
expected duration
• Caused by trauma to the nerve or “electric shock”
on injection
• Risk is 1 : 1 200 000 for 0.5%, 2%, and 3% local
anesthetics
• Risk is 1 : 500 000 for 4% local anesthetics
• Most cases resolve in about eight weeks
Soft Tissue Trauma
• Caused by chewing or biting soft tissue while
numb
• What other types of local anesthetics could be used?
• What are some behavior management techniques
that could be used to help with the administration of
local anesthesia?
• What are the subjective signs of local anesthesia?
• Bilateral mandibular block does not increase the
risk of soft tissue trauma when compared to
unilateral mandibular block
• Use local anesthetics that minimize the residual
soft tissue anesthesia
• Advise caregivers of the amount of time that the
soft tissue will be numb
• If possible, have the child bite on cotton rolls
ligated with dental floss until the soft tissue
anesthesia has worn off
Signs ofLocal Anesthetic Toxicity (Overdose)
• Early signs: dizziness, anxiety, confusion,
tachycardia, increased blood pressure
• Later signs: seizure activity, bradycardia, cardiac arrest
Self‐Study Questions
1. What is the maximum mg/kg and total dose of:
(a) lidocaine, (b) mepivacaine, and (c) articaine?
2. What is the total amount of lidocaine that can be
given to this child if he weighs 52 pounds?
3. What is an anatomical difference between
children and adults with respect to administration
of the inferior alveolar nerve block?
4. What is the mechanism of action of local
anesthetics?
5. What are the signs of local anesthetic toxicity?
Answers are located at the end of the case
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Self‐Study Answers
1. The maximum mg/kg and total doses of commonly
used local anesthetics in pediatric dentistry are: (a)
lidocaine: 4.4 mg/kg (2 mg/lb), 300 mg total;
(b)mepivacaine 4.4 mg/kg (2 mg/lb) 300 mg total;
(c)articaine 7.0 mg/kg (3.2 mg/lb) 500 mg total
2. A 52‐pound child could receive a total of 104 mg
of lidocaine
3. The mandibular foramen is lower than the
occlusal plane in children, so the injection should be
made lower and slightly more posterior in children
Bibliography
American Academy of Pediatric Dentistry. 2018–2019. Use of
local anesthesia for pediatric dental patients. In: Clinical
Practice Guidelines and Best Practices (Reference Manual).
Pediatr Dent 40:274–80. https://www.aapd.org/research/oral‐
health‐policies‐‐recommendations/use‐of‐local‐anesthesia‐
for‐pediatric‐dental‐patients
4. Local anesthetics act by interfering with the entry
of sodium ions in sodium channels of the nerve cell
membrane
5. The signs of local anesthetic toxicity are a central
nervous system excitatory phase (dizziness, anxiety,
confusion, tachycardia, increased blood pressure)
followed by depression of the central nervous
system (seizure activity, bradycardia, cardiac arrest)
Gosnell ES, Thikkurissy S. 2019. Assessment and management
of pain in the pediatric patient. In: Pediatric Dentistry: Infancy
through Adolescence, 6th edition. Nowak A, et al. (eds).
Philadelphia: Elsevier.
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BEHAVIOR GUIDANCE ANDMEDICAL EMERGENCIES
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Case 3
Nitrous Oxide/Oxygen Sedation
D. Medical History
• Review of systems positive for exercise‐induced
asthma and sickle cell trait
• No known drug or food allergies
• Albuterol when necessary
• Tonsils and adenoids removed at age five
• American Society of Anesthesiologists (ASA) 2
Figure 6.3.1 Facial photograph.
A. Presenting Patient
• Seven-year-, six‐month old African‐American male
(Figure6.3.1)
Chief Complaint andHistory of
B.
PresentIllness
• Mother states, “My child needs a few fillings done
with ‘laughing gas’ because he is really nervous about
getting a shot”
E. Medical Consult
• Not necessary at this time
F. Dental History
• Patient sees family dentist for recall visits every six
months
• Patient drinks juice and has cariogenic snacks
throughout the day
• Patient lives in fluoridated community, and mother
states that she assists with night‐time brushing with
fluoride toothpaste
• Does not floss
• No trauma history
• Treatment was previously attempted with local
anesthetic only but was aborted due to poor behavior
• Child appears moderately anxious, but has cooperated
for dental exams and radiographs in the past
G. Extraoral exam
• Head and neck: within normal limits
• Weight, height, body mass index: within normal limits
• Exposed extremities: within normal limits
C. Social History
• Mother is primary caregiver
• Patient lives at home with both parents and one
sister, age four
• Lower socioeconomic status
• Patient participates in afterschool swimming
H. Intraoral exam
• Soft tissue: within normal limits
• Hard tissue: within normal limits
• Dentition: mixed dentition with multiple carious
lesions
• Occlusion: class I
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I. Diagnostic Tools
• Radiographs: bitewing radiographs show multiple
interproximal carious lesions
J. Differential Diagnosis
• Not applicable
K. Diagnosis andProblem List
Diagnosis
• Dental caries
Problem List
• Poor oral hygiene and diet
• Moderate anxiety
BACKGROUND INFORMATION 1
Nitrous Oxide
• Colorless and virtually odorless
• Analgesic/anxiolytic agent
• Causes euphoria and slight central nervous system
depression, without respiratory compromise
• Works on the gamma‐aminobutyric acid type A
receptors
• Can increase sedative effect of other drugs
(Litmanetal. 1998)
• Multiple interproximal cavities
• Caries risk assessment is high
L. Comprehensive treatment plan
• Complete nutritional counseling and oral hygiene
instructions
• Restorative treatment
• Nitrous oxide/oxygen for treatment to address
moderate anxiety (see Background Information 1).
Obtain specific consent
• Prescribe high fluoride toothpaste
• Recall plan: three‐month recall due to high caries risk
Advantages
• Rapid onset and recovery time
• Ease of titration
• Few serious side‐effects
• Excellent safety record
American Academy of Pediatric Dentistry [AAPD]
2018–2019a
Disadvantages
• Weak agent
• Potential for occupational hazards (Centers for Disease
Control and Prevention [CDC] 2014; AAPD 2018–2019b)
• Depends on patient acceptance
• Patient must be able to breathe through nose and
tolerate nasal hood (Figure6.3.2)
M. Prognosis andDiscussion
• This case has a good prognosis. However, the patient
needs to modify diet and oral hygiene behavior in
order to avoid future caries
• As the child is only displaying moderate anxiety, and
has been cooperative previously, nitrous oxide/oxygen
Figure 6.3.2 Patient wearing properly adjusted nasal
hood.
Potential for diffusion hypoxia: insufficient
•
oxygenation at end of procedure may cause rapid
release of nitrous oxide from blood stream into
alveoli which could dilute concentration of oxygen
in the lungs and lead to hypoxia. Headache and
disorientation are early signs
should help him cooperate for his dental treatment
(see Fundamental Points 1 and 2)
• Multiple visits may be necessary to complete the
treatment plan
• Plan to capitalize on strong placebo effect to
incrementally ween patient off nitrous oxide/oxygen
with each visit as treatment progresses
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FUNDAMENTAL POINT 1
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BEHAVIOR GUIDANCE ANDMEDICAL EMERGENCIES
Indications andContraindications fortheuse
ofNitrous Oxide/Oxygen (AAPD 2018–2019a)
Indications
• A moderately fearful, anxious, or obstreperous
patient
• Patients with mild to moderate asthma
• A patient whose gag reflex interferes with
dentalcare
• A patient for whom profound local anesthesia
cannot be obtained
N. Common Complications andAlternative
Treatment Plans
• Nausea and vomiting are the most common side
effects of nitrous oxide. Typically caused by a large
meal prior to treatment, longer treatment times, and
high nitrous oxide concentrations or frequent
fluctuations in levels
• Sickle cell trait is not a contraindication to the use of
nitrous oxide. However, if the patient develops sickle
Contraindications
• Some chronic obstructive pulmonary diseases
• Current upper respiratory infections
• Recent middle ear disturbance/surgery
• Severe emotional disturbances or drug‐related
dependencies
• First trimester of pregnancy
• Treatment with bleomycin sulfate (chemotherapy agent)
• Methylenetetrahydrofolate reductase deficiency
• Cobalamin (vitamin B12) deficiency
cell disease, consultation with a physician would be
recommended prior to use
• Nitrous oxide is indicated for use in patients with
mild to moderate asthma since it can reduce anxiety
and therefore may reduce the risk of an asthmatic
episode
• If nitrous oxide/oxygen does not control the patient’s
anxiety, then moderate sedation or general
anesthesia may need to be considered
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FUNDAMENTAL POINT 2
Technique ofAdministration
• Avoid a large meal prior to administration to reduce
risk of nausea and vomiting
• Select proper size nasal hood
• Flow rate of 5 to 6 l/min of combined nitrous oxide
and oxygen. Check fail‐safe valve which prevents
ow if there is no oxygen (Rose and McLarney
2014) (Figure6.3.3)
• Administer 100% O2 for one to two minutes
• Begin titration of nitrous oxide increasing by 10%
increments every three to four minutes
A
•
Do not exceed 50%
• Maintain proper scavenging to reduce ambient
levels (CDC 2014; AAPD 2018–2019b)
• During treatment, visual monitoring of patient’s
respiratory rate and level of consciousness
• Patient more compliant and open to suggestion
• Communicative techniques more effective with
nitrous oxide/oxygen
• Once procedure is completed, 100% O
given
2
forve minutes to avoid diffusion hypoxia
(AAPD2018–2019a)
B
Figure 6.3.3 Nitrous oxide/oxygen delivery unit. (A) Nitrous oxide (blue) and oxygen (green) tanks; (B) regulator.
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Self‐Study Questions
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BEHAVIOR GUIDANCE ANDMEDICAL EMERGENCIES
1. If a child is treated successfully with 50% nitrous
oxide/oxygen, what should the concentration be for
subsequent restorative visits?
2. While administering nitrous oxide/oxygen
sedation you notice that both the oxygen and
nitrous ow meters drop to zero. What is the most
likely cause?
3. What are the contraindications to the use of
nitrous oxide?
4. What is the maximum recommended percent of
nitrous oxide?
5. What may cause nausea and vomiting during
nitrous oxide use?
Answers are located at the end of the case
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Self‐Study Answers
1. Reduce the concentration of nitrous oxide
incrementally with each visit in order to ween the
patient off as treatment progresses
2. The oxygen cylinder is empty. All nitrous
oxideunits are equipped with an oxygen–nitrous
oxide fail‐safe valve. This works to shut off the
nitrous oxide when there is a loss of oxygen
pressure
Bibliography
American Academy of Pediatric Dentistry. 2018–2019a. Use of
nitrous oxide for pediatric dental patients. In: Clinical Practice
Guidelines and Best Practices (Reference Manual). Pediatr
Dent 40(6):281–6.
American Academy of Pediatric Dentistry. 2018–2019b. Policy
on minimizing occupational health hazards associated with
nitrous oxide. In: Clinical Practice Guidelines and Best
Practices (Reference Manual). Pediatr Dent 40:104–5.
https://www.aapd.org/research/oral‐health‐policies‐‐
recommendations/minimizing‐occupational‐health‐hazards‐
associated‐with‐nitrous‐oxide
3. Cobalamin deficiency, treatment with bleomycin
sulfate, and methylenetetrahydrofolate reductase
deficiency
4. Fifty percent nitrous oxide
5. A large meal prior to treatment, longer treatment
times, and high nitrous oxide concentrations or
frequent fluctuations in levels
Centers for Disease Control and Prevention. 2014. Control of
nitrous oxide in dental operatories. Available at: https://
www.cdc.gov/niosh/docs/hazardcontrol/hc3.html
Litman RS, Kottra JA, Verga KA et al. 1998. Chloral hydrate
sedation: the additive sedative and respiratory depressant
effects of nitrous oxide. Anesth Analg 86:724–8.
Rose G, McLarney J. 2014. Chapter11: Fail‐safe systems. In:
Anesthesia Equipment Simplified. New York: McGraw‐Hill.
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Case 4
Pharmacological Behavior Guidance
• No known allergies to any foods or medications
• No medications
• Hospitalization at age three for dental treatment
under general anesthesia
• American Society of Anesthesiologists (ASA) class I
(see Fundamental Point 1)
E. Medical Consult
• Not necessary at this time
Figure 6.4.1 Facial photograph.
A. Presenting Patient
• Four‐year‐, ten‐month‐old Hispanic male (Figure6.4.1)
B. Chief Complaint
• Mother states, “My son is here to have his cavities fixed”
C. Social History
• Mother is the primary caregiver
• Patient lives with parents and one brother, age ten
• Mother works full‐time outside the home; father is
unemployed
• Lower socioeconomic status
D. Medical History
• Review of systems is negative
F. Dental History
• Highly cariogenic diet with frequent sugared soft
drinks and snacks
• Patient lives in a fluoridated community using city
water, and mother states the child brushes his teeth
once every day with fluoridated toothpaste without
supervision; does not floss
• Patient was treated for full mouth dental rehabilitation
under general anesthesia in the ambulatory care
center at age three. Treatment also included surgical
repair of a left mandibular abscess that had resulted
in left facial cellulitis
• After the initial postoperative follow‐up appointment
the patient did not return for recall visits
• No history of trauma
• Patient is uncooperative and extremely anxious,
clinging to his mother
G. Extraoral Exam
• Head and neck: within normal limits
• Weight and height, body mass index: within normal
limits
• Exposed extremities: within normal limits, negative
for bruising
• Other: heart sounds normal, breath sounds clear with
no evidence of upper respiratory infection
• Patient has not taken any food or liquid by mouth
(NPO) since midnight
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