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CHAPTER 6
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Self‐Study Answers
1. The bag‐valve‐mask device, connected to oxygen,
used by either one or two rescuers
2. The least invasive yet maximally effective adjunct
should be chosen first to minimize increasing the
child’s anxiety. Start with an oxygen cannula or
simple face mask, call 911, and continually assess
the child’s respiratory pattern to determine the need
for more invasive airway support requirements
3. No, an oral airway in any awake patient will only
stimulate the gag reflex and possibly cause
laryngospasm
4.
A non‐rebreather mask will deliver nearly 100%
oxygen if connected correctly to an oxygen source
delivering 10–15 l/minute of oxygen to a patient who
is breathing spontaneously
Bibliography
American Heart Association. 2016. The Pediatric Advanced Life
Support Manual.
Butterworth JF, Mackey DC, Wasnick JD (eds) 2013. Morgan
and Mikhail’s Clinical Anesthesiology, 5th Edition. New York:
McGraw‐Hill.
To manage a child with a partial airway
5.
obstruction, first make sure the airway is positioned
correctly. Obtain a good seal with the face mask by
pulling the child’s face into the mask, and creating a
seal with the index finger and thumb (review the E‐C
technique from the Pediatric Advanced Life Support
Manual, American Heart Association). Be sure to
stay off the soft tissue under the mandible and
provide supplemental oxygen. Do not use an oral
airway in a child who is conscious
Nafiu OO, Reynolds PI, Bamgbade OA etal. 2007. Childhood
body mass index and perioperative complications. Paediatr
Anaesth 17(5):426–30.
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Case 6
AB
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Allergic Reactions
BEHAVIOR GUIDANCE ANDMEDICAL EMERGENCIES
Figure 6.6.1 (A, B) Facial photographs.
A. Presenting Patient
• Three‐year-, two‐month‐old Caucasian male
(Figure6.6.1)
B. Chief Complaint
• Mother states, “My son needs his teeth cleaned”
C.
Social History
• Parents are separated
• Mother is the primary caregiver and works full‐time
• Patient has two healthy siblings, ages eight and 11,
with some environmental allergies
• Middle class socioeconomic status
D. Medical History
• Review of systems is negative
• Allergic to bananas and mangoes, mild dermatitis
upon exposure (see Fundamental Point 1 and
Background Information 1)
• No allergies to medications
• No routine over‐the‐counter or prescription
medications
• No previous hospitalizations or surgeries
• No emergency room visits
E. Medical Consult
• Consultation with primary care provider to confirm
food allergies
• Request test for sensitivity to latex
F.
Dental History
• Has had regular dental visits since age two
• Positive behavior for all recalls
• Optimal water fluoridation
• Healthy, low cariogenic diet
• Brushes once or twice a day, usually unsupervised
Note: If latex allergy is suspected, but not yet confirmed, then latex‐free materials should be used to
conduct exam, radiographs, and dental prophylaxis
G. Extraoral Exam
• Head and neck: within normal limits
• No significant findings
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CHAPTER 6
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FUNDAMENTAL POINT 1
Latex Allergy
• Food allergies that should alert the practitioner to a
possible latex allergy include: bananas, mangoes,
avocados, kiwis, and passion fruit
• Reactions to these foods should be noted in the
medical history
• Symptoms upon exposure to latex should be
gathered in the medical history. In children, lip
swelling or itching upon exposure to balloons can
be an indication of latex sensitivity
• Latex anaphylaxis in children has an estimated
incidence of one in 10 000
H. Intraoral Exam
Soft Tissues
• Mild plaque accumulation, mild gingivitis
Hard Tissues
• Full primary dentition, no cavities
Occlusion
• Within normal limits
I. Diagnostic Tools
• Bitewing and occlusal radiographs show no cavities
Chronic exposure to latex and a history of atopy (an
•
immediate reaction) increases the risk of
sensitization; children who have a history of multiple
surgeries or frequent exposure to urinarycatheters
are possibly at risk for latexallergy
• Latex allergies range in severity from mild dermatitis
to life‐threatening anaphylactic reactions
• Most serious latex reactions involve a direct
immunoglobulin E- (IgE) mediated response to the
polypeptides found in natural latex
(Butterworth etal. 2013)
J. Differential Diagnosis
• Not applicable
K. Diagnosis andProblem List
Diagnosis
• Good oral health
Problem List
• Food allergies
• Fair oral hygiene
BACKGROUND INFORMATION 1
Etiology andPhysiology ofAllergic Reactions
(Malamed 2015)
• Allergic reactions are exaggerated immunological
responses to allergens
Exposure can occur via the nose, eyes, skin, lungs,
•
gastrointestinal tract, or intravenously/ intramuscularly
• Common causes of allergies include certain foods,
medications, animals, insect venom, cosmetics,
perfumes, and latex
• Type I, or immediate, hypersensitivity reactions
involve antigens cross‐linking with IgE antibodies.
This cross‐link triggers mast cells to release
inflammatory mediators. Severe allergic reactions,
or anaphylaxis, can result. In anaphylactic IgE‐
mediated allergic reactions, the body produces
antibodies to a substance on first exposure. On
second exposure, the body releases the antibodies
and huge amounts of histamine. This can be
250 Clinical Cases inPediatric Dentistry
potentially life threatening without immediate
intervention
•
Type II, or cytotoxic, hypersensitivity reactions
involve immunoglobulin G (IgG)-antibodies, which
bind with antigens on cell surfaces. This IgG binding
causes cell lysis, i.e. hemolytic transfusion reactions
Type III, or immune complex, hypersensitivity
•
reactions occur when antigen-antibody complexes
are deposited into tissues. After the complex is
deposited, neutrophils are activatedand cause
tissue injury from the release of lysosomal
enzymes and other toxic products
• Type IV, or delayed/cell‐mediated, hypersensitivity
reactions are mediated by Tlymphocytes that have
been exposed to the antigen before. Re‐exposure
to the antigen causes the production of
lymphokines that activate inflammatory cells over
about 48–72hours, i.e. contact dermatitis
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BEHAVIOR GUIDANCE ANDMEDICAL EMERGENCIES
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L. Comprehensive Treatment Plan
• Dental prophylaxis
• Fluoride varnish application
• Improve oral hygiene
• Must rule out latex allergy
• Continue six‐month recalls
M. Prognosis andDiscussion
• This cavity‐free child is in good oral health but needs
to improve his oral hygiene practices by brushing more
and with parental assistance and supervision. Iflatex
FUNDAMENTAL POINT 2
Recognizing Symptoms of Allergic Reactions
• Symptoms of allergic reactions can range from
mild to severe
• Mild symptoms include watery, itchy eyes with a
rash and possibly nose and/or chest congestion
• Moderate reactions can include the above symptoms,
but also display itchiness and/or difculty breathing
• Severe allergic reactions, or anaphylaxis, result in
differing degrees of angioedema (swelling) that can
make it difcult for the patient to swallow or
breathe. Other symptoms include:
sensitivity is found to be positive, then
properprecautions should be takento avoid latex
exposure (see Fundamental Points 2 and 3)
N. Common Complications andAlternative
Treatment Plans
• What complications should you be prepared for in a
patient with known allergies to mangoes and
bananas?
• What preparations should you make for this patient’s
visit?
Abdominal pain, vomiting
Cramps, diarrhea
Mental confusion and/or dizziness
• Other clinical signs and symptoms of allergic
reactions include:
Tachycardia, hypotension, arrhythmias
Cough, bronchospasm, laryngeal edema, hypoxia
Facial edema, pruritus, generalized itching
• Symptoms of anaphylaxis appear quickly and can
include increased heart rate, extreme shortness of
breath, sudden weakness, a drop in blood
pressure, shock, unconsciousness, anddeath
FUNDAMENTAL POINT 3
Treatment ofAllergic Reactions
• If an allergic reaction is suspected due
todrugadministration, discontinue the
medication
• Discontinue all sources of the allergy‐causing
substance
• Administer diphenhydramine:
Children: 1 mg/kg by mouth q.i.d., 0.5–1 mg/kg
intravenous
Adults: 25–50 mg by mouth q.i.d.
• For anaphylactic reactions, recognize a true medical
emergency:
Call 911
Administer epinephrine (intramuscular or
subcutaneous), 0.01 mg/kg q five minutes
Administer supplemental oxygen
Monitor vital signs
Provide airway support as required
• Consult the American Academy of Pediatric
Dentistry (AAPD) guidelines on the management
of medical emergencies (AAPD 2018–2019)
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Self‐Study Questions
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BEHAVIOR GUIDANCE ANDMEDICAL EMERGENCIES
1. What are some common potential triggers of
allergic reactions in a dental ofce?
2. Type I, or immediate, hypersensitivity reactions
are modulated by which immunoglobulin?
3. Anaphylactic reactions occur after the second
exposure to an allergen (antigen), upon which the
body releases which substance?
4. State the common signs and symptoms of an
allergic reaction
5. State the common food allergies that would
make you suspicious that your patient has a latex
allergy
Answers are located at the end of the case
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CHAPTER 6
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Self‐Study Answers
1. Common triggers of allergies in the office setting
include anything containing latex (gloves, the
powder inside gloves, rubber dams, tourniquets),
medications (especially antibiotics), some local
anesthetics (rare allergies)
2. Type I, or immediate, hypersensitivity reactions
are modulated by IgE
3. Anaphylactic reactions occur after the body has
been sensitized to the antigen upon first exposure.
The second and all subsequent exposures cause the
body to release massive amounts of histamine,
Bibliography
American Academy of Pediatric Dentistry. 2018–2019.
Management of medical emergencies. In: Clinical Practice
Guidelines and Best Practices (Reference Manual). Pediatr
Dent 40:513–14. https://www.aapd.org/globalassets/media/
policies_guidelines/r_medemergencies.pdf
resulting in shortness of breath, tachycardia, and
rapidly declining cardiovascular function
4. The common signs and symptoms of an allergic
reaction include watery, itchy eyes with a rash and
possibly nose and/or chest congestion; generalized
itchiness and/or difficulty breathing; and tachycardia,
hypotension, arrhythmias, cough, bronchospasm,
laryngeal edema, hypoxia, and facial edema
5. The common food allergies that should alert the
practitioner to a potential latex allergy include
mangoes, bananas, avocados, passion fruit, and kiwis
Malamed SF. 2015. Medical Emergencies in the Dental Office,
7th Edition. 2015. St Louis: Mosby.
Morgan GE, Mikhail MS, Murray MJ. 2013. Clinical
Anesthesiology, 5th Edition. Butterworth JF, Mackey DC,
Wasnick JD (eds). New York: McGraw‐Hill.
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Case 7
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General Anesthesia
BEHAVIOR GUIDANCE ANDMEDICAL EMERGENCIES
Medical History
D.
• Review of systems is positive for sickle cell trait
• Allergy to penicillin; mother reports the child
developed a rash with amoxicillin
• No routine medications
• No previous hospitalizations or surgeries
• No emergency room visits
Figure 6.7.1 Facial photograph.
A. Presenting Patient
• Three‐year‐, seven‐month‐old Hispanic female
(Figure6.7.1)
B. Chief Complaint
• Mother states, “My daughter has some bad teeth
and she would not let the other dentist treat her”
C. Social History
• Parents are divorced
• Mother is the primary caregiver and works outside
the home on a part‐time basis
• Child lives with mother, grandmother, and two
siblings, ages two and seven
• Lower socioeconomic status
E. Medical Consult
• Request medical consult by pediatrician to update
status of sickle cell trait and allergies
F. Dental History
• This is the patient’s third dental visit
• She was previously seen for a new patient
examination and an attempt at restorative
treatment with nitrous oxide and local anesthesia
• The patient lives in a fluoridated community and uses
city water
• Mother brushes the child’s teeth once daily with a
fluoridated toothpaste but does not floss
• Highly cariogenic diet
•
No history of dental trauma
G. Extraoral Exam
• The patient appears hesitant as she and her mother
are escorted to the operatory
• Head and neck: within normal limits
• Weight and height, body mass index: within normallimits
• Exposed extremities (bruising, etc.): within normallimits
H. Intraoral Exam
Soft Tissues
• Within normal limits
Hard Tissues
• Extensive dental decay involving all four quadrants
and the maxillary anterior teeth
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CHAPTER 6
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Dentition
• Full primary dentition
Occlusion
• Mesial step with normal overjet and overbite
I. Diagnostic Tools
• Bitewing radiographs from previous office confirm
extensive interproximal decay
J. Differential Diagnosis
• Not applicable
K. Diagnosis andProblem List
(seeFundamental Point 1)
Diagnosis
• Severe early childhood caries
Problem List
• Extremely apprehensive patient
• No dental home
FUNDAMENTAL POINT 1
Indications forGeneral Anesthesia in
Pediatric Dentistry
• Certain physical, mental, or medically
compromising conditions
• Ineffective local anesthesia due to acute
infection, anatomic variations, or allergy
• Extremely uncooperative, fearful, anxious,
physically resistant, or uncommunicative child or
adolescent in whom there is no expectation that
the behavior will soon improve
Extensive orofacial/dental trauma
•
• Patients with immediate needs who would not
otherwise receive comprehensive care
• Patients in whom use of general anesthesia may
protect the developing psyche or reduce medical
risks
Contraindications forGeneral Anesthesia
• Unsuitable general anesthesia risk
• Respiratory infection
• Active systemic disease with elevated temperature
• No‐food‐by‐mouth (NPO) guidelines violated
• Healthy cooperative patient with minimal
dentalneeds
(Turner and Hipp 2018; Weddell et al. 2016)
• Poor diet
• Poor oral hygiene
L. Comprehensive Treatment Plan
• Establish dental home
• Patient is apprehensive and keeps asking, “Are you
going to stick me with a needle like the other dentist
did?” Due to anxiety, inability to cooperate, and the
extent of the restorations, treatment will require the
use of general anesthesia
• Implement aggressive caries prevention plan
• Recall visits every three months
Postoperative Instructions
• Minimize vigorous activity for the patient
• Pay attention to lip numbing and potential for self‐
inflicted trauma
• Maintain a bland and soft diet for the day
• Follow‐up with a visit in two weeks
M. Prognosis andDiscussion
• The use of general anesthesia provided an extremely
high likelihood that treatment will be completed, and
in one visit (Figure6.7.2)
• Parents need to be well informed of all the risks
and benefits of treatment under general
anesthesia
• The parent should be presented with the option of
having the general anesthesia performed in a hospital
or an in‐office setting
• It is important the anesthesia provider and the nursing
staff be made aware of the allergy to penicillin and
the positive sickle cell trait
N. Common Complications andAlternative
Treatment Plans
• The most common obstacles to general anesthesia
treatment are preoperative complications such as
illness or poor compliance with no food by mouth
(NPO) instructions (see Background Information 1)
In the postoperative period there is a risk of
•
nauseaand vomiting, and sore throat from the
endotracheal tube
• If the parent does not want to use sedative agents or
general anesthesia, attempts could be made to arrest
the caries or place interim restorations while trying to
reduce the patient’s anxiety with short, easy visits.
This approach may also be used to “buy time” until
the child matures and becomes more willing to
cooperate. Care must be taken to follow the child
closely and parents should understand that restorative
treatment will eventually be needed
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BEHAVIOR GUIDANCE ANDMEDICAL EMERGENCIES
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A B
Figure 6.7.2 (A, B) Intubated patient in operating room.
BACKGROUND INFORMATION 1
Preanesthetic Feeding Guidelines forGeneral
Anesthesia (American Academy of Pediatric
Dentistry [AAPD] 2018–2019; American Society
ofAnesthesiologists 2017)
• Clear liquids up to two hours prior to the procedure
• Breast milk up to four hours prior to the procedure
Self‐Study Questions
1. What children are candidates for anesthesia on an
outpatient basis?
• Infant formula and nonhuman milk up to six hours
prior to the procedure
• Light meal up to six hours prior to the procedure
4. What type of training is needed for a dentist to
treat children under general anesthesia?
2. What information do you need to have prior to
scheduling a patient for general anesthesia?
3. What are the advantages and disadvantages that
general anesthesia provides in dental care to children?
Answers are located at the end of the case
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