Homelessness and Oral Health
“It’s hard to brush and floss on the streets”
Persons who are homeless have more grossly decayed and missing teeth than the general population and even the impoverished population living in residences. Homeless persons are 12 times more likely than individuals with stable housing to have dental problems. Persons living in unstable housing, such as a hotel or the residence of a friend or relative, are 6 times more likely to have dental problems. Homeless adults have more intensive dental problems, such as periodontal disease and edentulism (a complete lack of teeth); however, their use of dental services is less than the general population’s. Only 53 percent of toothless homeless individuals have complete sets of dentures, compared with 91 percent of the general population. In addition, 83 percent had not had a dental cleaning in the previous 4 years, a rate 4.6 times higher than in the general U.S. population.
The Oral Health Status of Homeless Children
More homeless children have never seen a dentist than children from families with low incomes who were living in houses. Among homeless children ages 5 to 9 years, 96 percent required dental care and 44 percent had pain or infection. A Boston survey reported that untreated tooth decay in permanent teeth among homeless children in New England was 7.7 times above the regional average.
The Oral Health Status of the Homeless Population
Who Are the Homeless? The Department of Housing and UrbanDevelopment (HUD) defines the homeless as persons who are living on the streets or in shelters, as well as those who are at imminent risk for becoming homeless.Each year an estimated 2 million people in the UnitedStates lack access to a conventional dwelling or residence. Families with children constitute an estimated 38 percent of the homeless population; children account for 25 percent of the homeless population. Causes of homelessness include untreated mental illness, substance abuse and unmet treatment needs,domestic violence, low-paying jobs, changes and cuts in public assistance, and lack of access to affordablehealth care.
Concerns and Consequences
In a national survey, ninety-eight percent of shelter staff said that dental services are important in returning homeless persons to mainstream American society. Tooth extraction is the least expensive type of dental care and is often the only choice for homeless individuals. Missing teeth diminish self-esteem and impair an individual’s ability to eat, get a job, and, ultimately, return to mainstream society.
This publication has been produced by Michelle Clark at the National Maternal and Child Oral Health Resource Center, supported at the National Center for Education in Maternal and Child Health under its cooperative agreement (MCU-119301) with the Maternal and Child HealthBureau, Health Resources and Services Administration, U.S. Department of Health and Human Services. June 1999.
Access to and Utilization of Health Services
Among all vulnerable populations, the homeless population probably has the least access to health services. They have no money, health insurance, or permanent residence, and health care providers are often unwilling to serve them. A recent study in Montreal showed that even if the homeless have the right to free basic dental services, dentists are reluctant to see them in their private offices, especially duringnormal office hours. Most homeless adults and their children are eligible for dental services through programs like Medicaid and CHIP. However, current outreach efforts are not adequate to reach manyhomeless families. Homeless persons with Medicaid coverage are more likely to receive dental services; however coverage varies from state to state. For example, Medicaid covers dentures in New Mexico, but will pay for only extractions in Ohio. In fiscal year 1998, the federal Health Care for the Homeless (HCH) program providedsupport to 128 grantees in 48 states, the District of Columbia, and the Commonwealth of Puerto Rico. Because funding is not specifically provided for dental clinics, grantees are encouraged but not required to furnish most dental services.
Sunday, December 21, 2008
Oral Disease: A crisis among children of poverty
Oral Disease:
A Crisis Among Children of Poverty
Almost 52 million school hours are missed annually by children because of oral problems. Extensive tooth decay, pain, or infection can cause eating, learning, and speech problems for
children. Many adolescents with oral problems such as decayed or missing teeth suffer embarrassment and diminished self-esteem.
Preventable oral diseases still afflict the majority of America’s children. This is especially true for children from families with low incomes, children in minority groups, and children with special health care needs. These children experience greater levels of disease and unmet need, and bear most of the burden of unnecessary pain, suffering, and compromise to their total health.
In the United States, 25 percent of children and adolescents—typically, the most vulnerable—experience 80 percent of all dental decay occurring in permanent teeth.
“Bleeding gums, impacted teeth, rotting teeth are routine matters in the children. . . . Children get used to feeling the constant pain. They go to sleep with it. They go to school with it. . . . The gradual attrition of accepted pain erodes energy and aspiration.” Jonathan Kozol
An estimated 5–10 percent of preschool-age children have baby bottle tooth decay/early childhood caries, a severe form of tooth decay. The percentage is even higher in certain populations: Survey results show that 20 percent of children from families with low incomes and 43 percent of children in some American Indian populations have baby bottle tooth decay/early childhood caries.
Baby bottle tooth decay/early childhood caries increases a child’s risk for future tooth decay. Children as young as age 1 experience untreated dental decay. Among children ages 6–8, 72
percent of American Indian/Alaskan Native children, 50 percent of Hispanic children, 34
percent of black children, and 31 percent of all children experience untreated dental decay. More than half of all children ages 6–8 and two-thirds of all 15-year-old adolescents experience
dental decay. Sixty percent of adolescents have gum disease.
Access Vulnerable populations of children (especially children from families with low incomes, those who are homeless, those in families without dental insurance, and those with special health
care needs) have more oral problems and less access to dental care than the general population.
These children suffer from frequent—often urgent—oral problems and generally receive
inadequate dental care. Serious facial swelling from a tooth abscess resulting from decay. Grossly decayed teeth require extensive treatment.
Oral Health Status
This publication has been produced by the National Maternal and Child Oral Health Resource
Center supported at the National Center for Education in Maternal and Child Health under its
cooperative agreement (MCU-119301) with the Maternal and Child Health Bureau, Health
Resources and Services Administration, Public Health Service, U.S. Department of Health and
Human Services, in collaboration with the Children’s Dental Health Project. May 1998.
The Cost of Care Individuals with the greatest need for oral health services are also the least likely to have dental coverage or to have the personal resources to purchase dental care. Inability to pay is the main barrier to visiting a dentist. Only one-fourth of all children ages 8
years and younger have private dental insurance, and the number of publicly financed dental
programs has not kept pace with the demand—and, in many cases, has declined.
In the United States, 30 percent of all children’s health expenditures are devoted to children’s
dental care—a spending rate more than 10 times that of the 2.3 percent expended by
Medicaid for children’s dental care.
The new State Children’s Health Insurance Program (CHIP) provides an opportunity to
expand health services for children. However, some states are not including dental services as
part of their plans, despite the fact that children from families with low incomes have the
least access to dental care and the greatest unmet need.
A Crisis Among Children of Poverty
Almost 52 million school hours are missed annually by children because of oral problems. Extensive tooth decay, pain, or infection can cause eating, learning, and speech problems for
children. Many adolescents with oral problems such as decayed or missing teeth suffer embarrassment and diminished self-esteem.
Preventable oral diseases still afflict the majority of America’s children. This is especially true for children from families with low incomes, children in minority groups, and children with special health care needs. These children experience greater levels of disease and unmet need, and bear most of the burden of unnecessary pain, suffering, and compromise to their total health.
In the United States, 25 percent of children and adolescents—typically, the most vulnerable—experience 80 percent of all dental decay occurring in permanent teeth.
“Bleeding gums, impacted teeth, rotting teeth are routine matters in the children. . . . Children get used to feeling the constant pain. They go to sleep with it. They go to school with it. . . . The gradual attrition of accepted pain erodes energy and aspiration.” Jonathan Kozol
An estimated 5–10 percent of preschool-age children have baby bottle tooth decay/early childhood caries, a severe form of tooth decay. The percentage is even higher in certain populations: Survey results show that 20 percent of children from families with low incomes and 43 percent of children in some American Indian populations have baby bottle tooth decay/early childhood caries.
Baby bottle tooth decay/early childhood caries increases a child’s risk for future tooth decay. Children as young as age 1 experience untreated dental decay. Among children ages 6–8, 72
percent of American Indian/Alaskan Native children, 50 percent of Hispanic children, 34
percent of black children, and 31 percent of all children experience untreated dental decay. More than half of all children ages 6–8 and two-thirds of all 15-year-old adolescents experience
dental decay. Sixty percent of adolescents have gum disease.
Access Vulnerable populations of children (especially children from families with low incomes, those who are homeless, those in families without dental insurance, and those with special health
care needs) have more oral problems and less access to dental care than the general population.
These children suffer from frequent—often urgent—oral problems and generally receive
inadequate dental care. Serious facial swelling from a tooth abscess resulting from decay. Grossly decayed teeth require extensive treatment.
Oral Health Status
This publication has been produced by the National Maternal and Child Oral Health Resource
Center supported at the National Center for Education in Maternal and Child Health under its
cooperative agreement (MCU-119301) with the Maternal and Child Health Bureau, Health
Resources and Services Administration, Public Health Service, U.S. Department of Health and
Human Services, in collaboration with the Children’s Dental Health Project. May 1998.
The Cost of Care Individuals with the greatest need for oral health services are also the least likely to have dental coverage or to have the personal resources to purchase dental care. Inability to pay is the main barrier to visiting a dentist. Only one-fourth of all children ages 8
years and younger have private dental insurance, and the number of publicly financed dental
programs has not kept pace with the demand—and, in many cases, has declined.
In the United States, 30 percent of all children’s health expenditures are devoted to children’s
dental care—a spending rate more than 10 times that of the 2.3 percent expended by
Medicaid for children’s dental care.
The new State Children’s Health Insurance Program (CHIP) provides an opportunity to
expand health services for children. However, some states are not including dental services as
part of their plans, despite the fact that children from families with low incomes have the
least access to dental care and the greatest unmet need.
US Dental Facts
American Dental Association
(ADA)WORKFORCE (latest data available 2002)
2004 Active Dentists Population/dentist:
(professionally active dentists) 169,894
men 141,104
women 28,190
in public services 3,095
in private practice 156,921
in universities 3,392
armed forces 2,426
in other related occupations
(Full-Time administrative posts, etc) 1,556
Chairside Assistants (dental nurses): N/A
Therapists: N/A
Dental Hygienists: N/A
Laboratory Technicians: N/A
Denturists: N/A
Other dental work categories – specify:
Based on primary occupation only
DENTAL EDUCATION 2004 Number of Dental Schools: (includes Puerto Rico) 56
List of Dental Schools (with addresses) Please attach attached
Do you have a vocational training? How long? N/A
Length of Curriculum: (except the University of the Pacific which has a 3-year curriculum) 4yr
Graduates Per Year: (latest data available 2002)* 4,349
Number of Schools for Therapists: N/A
Number of Schools for Hygienists: 278
Number of Schools for Chairside Assistants (dental nurses): 259
Number of Schools for Lab Technicians: 24
Recognised Specialities: No of Specialists
(these are practitioners with officially recognised qualificationsin a particular area):
(Among professionally active dentists)
General Practice No 143,7592
Oral and Maxillofacial Surgery No 6,589
Endodontics No 4,176
Orthodontics and Dentofacial Orthopedics No 9,509
Pediatric Dentistry No 4,402
Periodontics No 5,097
Prosthodontics No 3,247
Oral and Maxillofacial Pathology No 332
Dental Public Health No 851
Oral and Maxillofacial Radiology No 12
ORAL HEALTH CARE (latest available data 2002) 2004
Does your country have an oral health policy? If yes, please attach an electronic copy.
Varies by State
Oral health care free of charge for children up to what age
Varies by State
of all oral health care for children:
% delivered in public service:
% delivered in private practice
of all oral health care for adults:
% delivered in public service:
% delivered in private practice
Treatment costs covered by the social security system: (public sector ?) $4.5 Billion
Treatment costs covered by the private insurance: $34.8 Billion
Treatment costs entirely paid by patient: $30.9 Billion
Annual Expenditure on Oral Health as % of total expenditure on health 4.5%
LICENSURE
Authority: Authority to License dentists to practice dentistry belongs to each state, district ordependency regulatory agency known as the Board of Dentistry or the Board of Dental Examiners. Adental license issued by one jurisdiction (e.g., state) only applies to the geographic confines of that particular jurisdiction.
Requirements, Degrees, diplomas: To be eligible for dental licensure, dentists must have received a DDS (Doctor of Dental Surgery) or DMD (Doctor of Dental Medicine) form a dental school accredited bythe ADA Commission on Dental Accreditation or the Canadian Commission on Dental Accreditation. For individuals already licensed in one state, opportunities to move from state to state exist depending onspecific requirements in the state where they wish to move to practice. These individuals may apply for and receive “licensure by credentials” if they have met all requirements, e.g., if they have practiced in thestate where they currently hold a license for at least 5 years and have no actions taken against theirlicense by the board of dentistry.
National or state examinations necessary for registration: Candidates for licensure are required tosuccessfully complete Parts I and II of the National Board Dental Examination, which assess theoretical knowledge. In addition, candidates must successfully complete clinical examinations conducted byindividual state boards of dentistry of by a regional dental testing agency. Reciprocal agreements with (list of countries that enter into agreements allowing mutualexchange of workforce): There are no agreements allowing mutual exchange of workforce. Withregard to evaluation of the dental education programs, by reciprocal agreement between the ADA Commission on Dental Accreditation and the Canadian Dental Association’s Commission on Dental Accreditation, graduates of these programs may be eligible for licensure in each country.
CONTINUING EDUCATION
Is continuing education mandatory?
Most states (47) one territory and one district of the U.S. have mandatory continuing education requirements for continued licensure. If mandatory, when was it introduced and how many hours or days per year? The first state to mandate CE for re-licensure was Minnesota in 1969. An additional few states and oneterritory mandated CE in the 1970s. Most states and one district mandated CE in the 1980s and 1990s. Since 2000, additional states have mandated CE. The number and type of CE credits required and the frequency of auditing is established by the state, territory or district. The number of CE credits required varies from 15 hours to 30 hours per year, with most being 20-25 hours per year. For more detailed information (current as of September 1, 2004), see the attached document, CE Requirements of State Dental Boards for Dentists and Auxiliaries, ADA Department of State Government Affairs.
USEFUL ADDRESSES
Licensure Body See attached list of State Board of Dental Examiners
Ministry of Health N/A
Chief Dental Officers N/A
Dental Industry Associations
American Dental Trade Association, 4222 King Street West, Alexandria, VA 22302-1597
Dental Dealers of America, Suite 2030, 123 South Broad Street, Philadelphia, PA 19109-1020
Dental Manufacturers of America, Inc., Suite 2030, 123 South Broad Street, Philadelphia, PA 19109-1020
Other
American Association of Dental Examiners, Suite 760, 211 East Chicago Avenue, Chicago, IL60611-2616
American Dental Assistants Association, 35 East Wacker Drive, Chicago, IL 60601-2211
American Dental Education Association, 1400 K Street, NW, Suite 1100, Washington, DC 20005
American Dental Hygienists Association, Suite 3400, 444 North Michigan Avenue, Chicago, IL60611-2616
National Association of Dental Laboratories, 1530 Metropolitan Boulevard, Tallahassee, FL 32308
(ADA)WORKFORCE (latest data available 2002)
2004 Active Dentists Population/dentist:
(professionally active dentists) 169,894
men 141,104
women 28,190
in public services 3,095
in private practice 156,921
in universities 3,392
armed forces 2,426
in other related occupations
(Full-Time administrative posts, etc) 1,556
Chairside Assistants (dental nurses): N/A
Therapists: N/A
Dental Hygienists: N/A
Laboratory Technicians: N/A
Denturists: N/A
Other dental work categories – specify:
Based on primary occupation only
DENTAL EDUCATION 2004 Number of Dental Schools: (includes Puerto Rico) 56
List of Dental Schools (with addresses) Please attach attached
Do you have a vocational training? How long? N/A
Length of Curriculum: (except the University of the Pacific which has a 3-year curriculum) 4yr
Graduates Per Year: (latest data available 2002)* 4,349
Number of Schools for Therapists: N/A
Number of Schools for Hygienists: 278
Number of Schools for Chairside Assistants (dental nurses): 259
Number of Schools for Lab Technicians: 24
Recognised Specialities: No of Specialists
(these are practitioners with officially recognised qualificationsin a particular area):
(Among professionally active dentists)
General Practice No 143,7592
Oral and Maxillofacial Surgery No 6,589
Endodontics No 4,176
Orthodontics and Dentofacial Orthopedics No 9,509
Pediatric Dentistry No 4,402
Periodontics No 5,097
Prosthodontics No 3,247
Oral and Maxillofacial Pathology No 332
Dental Public Health No 851
Oral and Maxillofacial Radiology No 12
ORAL HEALTH CARE (latest available data 2002) 2004
Does your country have an oral health policy? If yes, please attach an electronic copy.
Varies by State
Oral health care free of charge for children up to what age
Varies by State
of all oral health care for children:
% delivered in public service:
% delivered in private practice
of all oral health care for adults:
% delivered in public service:
% delivered in private practice
Treatment costs covered by the social security system: (public sector ?) $4.5 Billion
Treatment costs covered by the private insurance: $34.8 Billion
Treatment costs entirely paid by patient: $30.9 Billion
Annual Expenditure on Oral Health as % of total expenditure on health 4.5%
LICENSURE
Authority: Authority to License dentists to practice dentistry belongs to each state, district ordependency regulatory agency known as the Board of Dentistry or the Board of Dental Examiners. Adental license issued by one jurisdiction (e.g., state) only applies to the geographic confines of that particular jurisdiction.
Requirements, Degrees, diplomas: To be eligible for dental licensure, dentists must have received a DDS (Doctor of Dental Surgery) or DMD (Doctor of Dental Medicine) form a dental school accredited bythe ADA Commission on Dental Accreditation or the Canadian Commission on Dental Accreditation. For individuals already licensed in one state, opportunities to move from state to state exist depending onspecific requirements in the state where they wish to move to practice. These individuals may apply for and receive “licensure by credentials” if they have met all requirements, e.g., if they have practiced in thestate where they currently hold a license for at least 5 years and have no actions taken against theirlicense by the board of dentistry.
National or state examinations necessary for registration: Candidates for licensure are required tosuccessfully complete Parts I and II of the National Board Dental Examination, which assess theoretical knowledge. In addition, candidates must successfully complete clinical examinations conducted byindividual state boards of dentistry of by a regional dental testing agency. Reciprocal agreements with (list of countries that enter into agreements allowing mutualexchange of workforce): There are no agreements allowing mutual exchange of workforce. Withregard to evaluation of the dental education programs, by reciprocal agreement between the ADA Commission on Dental Accreditation and the Canadian Dental Association’s Commission on Dental Accreditation, graduates of these programs may be eligible for licensure in each country.
CONTINUING EDUCATION
Is continuing education mandatory?
Most states (47) one territory and one district of the U.S. have mandatory continuing education requirements for continued licensure. If mandatory, when was it introduced and how many hours or days per year? The first state to mandate CE for re-licensure was Minnesota in 1969. An additional few states and oneterritory mandated CE in the 1970s. Most states and one district mandated CE in the 1980s and 1990s. Since 2000, additional states have mandated CE. The number and type of CE credits required and the frequency of auditing is established by the state, territory or district. The number of CE credits required varies from 15 hours to 30 hours per year, with most being 20-25 hours per year. For more detailed information (current as of September 1, 2004), see the attached document, CE Requirements of State Dental Boards for Dentists and Auxiliaries, ADA Department of State Government Affairs.
USEFUL ADDRESSES
Licensure Body See attached list of State Board of Dental Examiners
Ministry of Health N/A
Chief Dental Officers N/A
Dental Industry Associations
American Dental Trade Association, 4222 King Street West, Alexandria, VA 22302-1597
Dental Dealers of America, Suite 2030, 123 South Broad Street, Philadelphia, PA 19109-1020
Dental Manufacturers of America, Inc., Suite 2030, 123 South Broad Street, Philadelphia, PA 19109-1020
Other
American Association of Dental Examiners, Suite 760, 211 East Chicago Avenue, Chicago, IL60611-2616
American Dental Assistants Association, 35 East Wacker Drive, Chicago, IL 60601-2211
American Dental Education Association, 1400 K Street, NW, Suite 1100, Washington, DC 20005
American Dental Hygienists Association, Suite 3400, 444 North Michigan Avenue, Chicago, IL60611-2616
National Association of Dental Laboratories, 1530 Metropolitan Boulevard, Tallahassee, FL 32308
Thursday, December 18, 2008
Head Start
The Head Start program provides comprehensive developmental services for low-income preschool children between the ages of three and five and support services for their families. Head Start provides diverse services consistent with goals for: education, health, parent involvement and social services. Programs administered by the Office of Head Start also provide services for children of American Indian and migrant worker families, and include Early Head Start programs, which expand the benefits of Head Start to pregnant women and children from birth to age three.
Thumb, Finger and Pacifier Habits
Q: Why do children suck on fingers, pacifiers or other objects?
A: This type of sucking is completely normal for babies and young children. It provides security. For young babies, it's a way to make contact with and learn about the world. In fact, babies begin to suck on their fingers or thumbs even before they are born.
Q: Are these habits bad for the teeth and jaws?
A: Most children stop sucking on thumbs, pacifiers or other objects on their own between two and four years of age. No harm is done to their teeth or jaws. However, some children repeatedly suck on a finger, pacifier or other object over long periods of time. In these children, the upper front teeth may tip toward the lip or not come in properly.
Q: When should I worry about a sucking habit?
A: Your pediatric dentist will carefully watch the way your child's teeth come in and jaws develop, keeping the sucking habit in mind at all times. For most children the AAPD recommends encouraging these habits cease by age three.
Q: What can I do to stop my child's habit?
A: Most children stop sucking habits on their own, but some children need the help of their parents and their pediatric dentist. When your child is old enough to understand the possible results of a sucking habit, your pediatric dentist can encourage your child to stop, as well as talk about what happens to the teeth if your child doesn't stop. This advice, coupled with support from parents, helps most children quit. If this approach doesn't work, your pediatric dentist may recommend a mouth appliance that blocks sucking habits.
Q: Are pacifiers a safer habit for the teeth than thumbs or fingers?
A: Thumb, finger and pacifier sucking all affect the teeth essentially the same way. However, a pacifier habit is often easier to break.
Here are what some specialists say about pacifier use;
Dr. Michael Cabana,
chief of General Pediatrics at UCSF Children's Hospital
"There are potential benefits and potential pitfalls. On the plus side, pacifier use during sleep has been associated with a decreased risk of Sudden Infant Death Syndrome (SIDS). SIDS is most likely to occur in the first year of life. But the pacifier use does not guarantee that SIDS will not occur. The most important thing to prevent SIDS is to place babies to sleep on their back. On the negative side regarding pacifiers, their use may cause 'nipple confusion' and thus make breastfeeding less successful, but the evidence for this phenomenon is not strong. Some health care providers discourage the use of pacifiers for the first few weeks of life, until breastfeeding is firmly established. Prolonged use of pacifiers (for example, older children still using pacifiers) is associated with orthodontic issues (for example, crooked teeth that later require braces)."
Dr. Janet Stafford,
pediatrician at Kaiser Permanent San Francisco
"Every baby is unique. Every baby has a different neurological path of comfort. Some babies are extremely oral. They're born that way. They're satisfied when there's something in their mouth, a finger, a thumb, a nipple, a pacifier. If a pacifier is what satisfies that need, then I think it's OK to use one. But if a parent uses it rather than rocking or holding a baby, I would prefer the other. I advise most parents to edge their baby off the pacifier before the child turns 1-year-old. When you take the pacifier away, you can use your index finger to make little circles on the baby's cheek to help relax them. For older kids over 1 year old, I recommend a goodbye pacifier party where the child picks out wrapping paper and ribbon and wraps up the pacifier and throws it away saying it's going to another baby who needs it."
Dr. Janesta Noland,
a pediatrician at Burgess Pediatrics in Menlo Park
"I tell my patients they shouldn't use one. I'm a proponent for breastfeeding and I think there's a lot to be said for natural sucking and self-soothing. For my patients who do use them after breast-feeding is established, I say that at 6 months it really should only be used for sleep. At 12 months my recommendation is to give it up cold turkey."
Staci Sampo,
a lactation consultant at the John Muir Women's Health Center in Walnut Creek
"If the parents can avoid it, I tell them not to use it. Sometimes the pacifier satisfies the baby's need for sucking and so the baby isn't interested in breast-feeding and then loses weight. Often babies who are feeding well won't even take a pacifier. But if a mom can't stand to listen to her baby while she's driving then I say OK."
Dr. Thuan Le,
an assistant adjunct professor in UCSF's Division of Pediatric Dentistry
"I have no problem with the pacifier up until 2 years. After two years, the child is going to experience some skeletal and dental problems. If you quit before age 3, it will likely self-correct. But after 3 or 4 years the child will likely have permanent damage that might require orthodontic surgery."
Dr. Alan Greene,
a clinical professor in pediatrics at Standford's Lucile Packard Children's Hospital
"If a child is getting a lot of ear infections the first thing I would try--before antibiotics--is eliminating the pacifier. Studies have shown that pacifier use can increase the frequency of ear infections by as much as 50 percent, but only one-third of kids get ear infections and some of those kids use pacifiers and some don't."
A: This type of sucking is completely normal for babies and young children. It provides security. For young babies, it's a way to make contact with and learn about the world. In fact, babies begin to suck on their fingers or thumbs even before they are born.
Q: Are these habits bad for the teeth and jaws?
A: Most children stop sucking on thumbs, pacifiers or other objects on their own between two and four years of age. No harm is done to their teeth or jaws. However, some children repeatedly suck on a finger, pacifier or other object over long periods of time. In these children, the upper front teeth may tip toward the lip or not come in properly.
Q: When should I worry about a sucking habit?
A: Your pediatric dentist will carefully watch the way your child's teeth come in and jaws develop, keeping the sucking habit in mind at all times. For most children the AAPD recommends encouraging these habits cease by age three.
Q: What can I do to stop my child's habit?
A: Most children stop sucking habits on their own, but some children need the help of their parents and their pediatric dentist. When your child is old enough to understand the possible results of a sucking habit, your pediatric dentist can encourage your child to stop, as well as talk about what happens to the teeth if your child doesn't stop. This advice, coupled with support from parents, helps most children quit. If this approach doesn't work, your pediatric dentist may recommend a mouth appliance that blocks sucking habits.
Q: Are pacifiers a safer habit for the teeth than thumbs or fingers?
A: Thumb, finger and pacifier sucking all affect the teeth essentially the same way. However, a pacifier habit is often easier to break.
Here are what some specialists say about pacifier use;
Dr. Michael Cabana,
chief of General Pediatrics at UCSF Children's Hospital
"There are potential benefits and potential pitfalls. On the plus side, pacifier use during sleep has been associated with a decreased risk of Sudden Infant Death Syndrome (SIDS). SIDS is most likely to occur in the first year of life. But the pacifier use does not guarantee that SIDS will not occur. The most important thing to prevent SIDS is to place babies to sleep on their back. On the negative side regarding pacifiers, their use may cause 'nipple confusion' and thus make breastfeeding less successful, but the evidence for this phenomenon is not strong. Some health care providers discourage the use of pacifiers for the first few weeks of life, until breastfeeding is firmly established. Prolonged use of pacifiers (for example, older children still using pacifiers) is associated with orthodontic issues (for example, crooked teeth that later require braces)."
Dr. Janet Stafford,
pediatrician at Kaiser Permanent San Francisco
"Every baby is unique. Every baby has a different neurological path of comfort. Some babies are extremely oral. They're born that way. They're satisfied when there's something in their mouth, a finger, a thumb, a nipple, a pacifier. If a pacifier is what satisfies that need, then I think it's OK to use one. But if a parent uses it rather than rocking or holding a baby, I would prefer the other. I advise most parents to edge their baby off the pacifier before the child turns 1-year-old. When you take the pacifier away, you can use your index finger to make little circles on the baby's cheek to help relax them. For older kids over 1 year old, I recommend a goodbye pacifier party where the child picks out wrapping paper and ribbon and wraps up the pacifier and throws it away saying it's going to another baby who needs it."
Dr. Janesta Noland,
a pediatrician at Burgess Pediatrics in Menlo Park
"I tell my patients they shouldn't use one. I'm a proponent for breastfeeding and I think there's a lot to be said for natural sucking and self-soothing. For my patients who do use them after breast-feeding is established, I say that at 6 months it really should only be used for sleep. At 12 months my recommendation is to give it up cold turkey."
Staci Sampo,
a lactation consultant at the John Muir Women's Health Center in Walnut Creek
"If the parents can avoid it, I tell them not to use it. Sometimes the pacifier satisfies the baby's need for sucking and so the baby isn't interested in breast-feeding and then loses weight. Often babies who are feeding well won't even take a pacifier. But if a mom can't stand to listen to her baby while she's driving then I say OK."
Dr. Thuan Le,
an assistant adjunct professor in UCSF's Division of Pediatric Dentistry
"I have no problem with the pacifier up until 2 years. After two years, the child is going to experience some skeletal and dental problems. If you quit before age 3, it will likely self-correct. But after 3 or 4 years the child will likely have permanent damage that might require orthodontic surgery."
Dr. Alan Greene,
a clinical professor in pediatrics at Standford's Lucile Packard Children's Hospital
"If a child is getting a lot of ear infections the first thing I would try--before antibiotics--is eliminating the pacifier. Studies have shown that pacifier use can increase the frequency of ear infections by as much as 50 percent, but only one-third of kids get ear infections and some of those kids use pacifiers and some don't."
For Teenage Patients
A bright smile fresh breath – that’s what a healthy mouth means. It also means you can talk and laugh with confidence.
Here are facts, ideas and tips on keeping a healthy smile in your teenage years.
What You Need To Know about Your Dental Health
FACT 1: You have not outgrown tooth decay. In fact, dental decay may be more of a problem for you during the teen years than it ever has been before.
FACT 2: Gum disease (gingivitis) is a risk to your dental health. It is also a threat to your appearance. Gum disease causes red and swollen gums, bleeding gums and bad breath.
FACT 3: You will have all your permanent teeth with the possible exception of your wisdom teeth (third molars). During these growing years, your face and jaws will undergo many changes. You can be healthy and attractive through these changes by taking good care of your teeth and visiting your pediatric dentist.
How You Can Keep a Healthy SmileIt is up to you! What you do and do not do is important. Here is a checklist for a healthy smile:
Eat intelligently! Life is going to be hectic now. Choose fresh fruits and vegetables instead of junk foods when you eat on the run.
Snack smartly. Be careful of snack foods containing sugar; they can cause damage to the teeth and gums.
Practice good prevention at least twice a day. Brush effectively using a fluoridated toothpaste. Floss to prevent gum disease and tooth decay on the sides of the teeth.
Keep up with your dental checkups. Tooth cleanings, fluoride treatments and sealants are important preventive services for you.
Do not smoke or chew tobacco! The warnings you hear and read about are true. Besides lung and heart problems, tobacco can cause oral cancer. Of all cancers, 2.4 percent occur in the mouth and tobacco use has been estimated to account for over 90 percent of cancers of the oral cavity and pharynx.* If you are using tobacco and notice any changes in your mouth, contact your doctor immediately.
Wear a mouth guard for any sport or activity in which your mouth can be hit.
Buckle up in the car. A seat belt and shoulder harness can keep your face from striking the steering wheel, the dashboard or windshield during minor accidents.
Quiz on Eating DisordersYou (or a friend) may have an eating disorder if you answer YES to the following questions:
Do you weigh yourself more than once a day?
Are you obsessed with being very thin, even while you are below a normal weight?
Do you have a fear of not being able to stop eating?
Do you vomit after a meal – or have the urge to do so?
(For females only) Have you missed three consecutive menstrual periods?
All eating disorders have health risks. The worst cases can lead to death. Eating disorders associated with vomiting can damage the teeth because of stomach acid. If you suspect you have an eating disorder, please see your doctor as soon as possible.
Tips For Smart Snacking
Be careful of between-meal snacks.
Clear the snack from the teeth as soon as possible. Even a simple swish and rinse with water will help.
Do not let snacks take the place of nutritionally balanced meals.
How Your Pediatric Dentist Can HelpThere are many things a pediatric dentist can do to help assure your oral health for a lifetime. Preventive dentistry techniques such as tooth cleanings, sealants and fluoride treatments are just as important as ever for you. Tips on flossing and brushing, and ideas on snacking and choosing a healthy diet, are available to you from your pediatric dentist and staff as well.
Your pediatric dentist will be glad to talk to you about how your teeth look. If you feel your teeth are too dark, there are techniques now to whiten them. If you have broken teeth, teeth with defects or spaces between your teeth, there are a number of esthetic dentistry techniques to help you look better.
If you are concerned about your bite, crooked teeth or the appearance of your smile, your pediatric dentist can give you advice about correcting such problems.
During your teen years, your wisdom teeth (third molars) will be developing. Although some third molars come into the mouth normally, others need to be removed because of poor position and lack of space. Your pediatric dentist will make sure the proper treatment is prescribed at the right time.
Dentistry for adolescents and teens is a fundamental part of the advanced training of the pediatric dentist. Your dental health and appearance are as important to you and your pediatric dentist. Let us keep your smile sparkling and healthy.
Your pediatric dentist and the American Academy of Pediatric Dentistry hope this brochure is useful to you. Please share this information with a family member or friend.
Here are facts, ideas and tips on keeping a healthy smile in your teenage years.
What You Need To Know about Your Dental Health
FACT 1: You have not outgrown tooth decay. In fact, dental decay may be more of a problem for you during the teen years than it ever has been before.
FACT 2: Gum disease (gingivitis) is a risk to your dental health. It is also a threat to your appearance. Gum disease causes red and swollen gums, bleeding gums and bad breath.
FACT 3: You will have all your permanent teeth with the possible exception of your wisdom teeth (third molars). During these growing years, your face and jaws will undergo many changes. You can be healthy and attractive through these changes by taking good care of your teeth and visiting your pediatric dentist.
How You Can Keep a Healthy SmileIt is up to you! What you do and do not do is important. Here is a checklist for a healthy smile:
Eat intelligently! Life is going to be hectic now. Choose fresh fruits and vegetables instead of junk foods when you eat on the run.
Snack smartly. Be careful of snack foods containing sugar; they can cause damage to the teeth and gums.
Practice good prevention at least twice a day. Brush effectively using a fluoridated toothpaste. Floss to prevent gum disease and tooth decay on the sides of the teeth.
Keep up with your dental checkups. Tooth cleanings, fluoride treatments and sealants are important preventive services for you.
Do not smoke or chew tobacco! The warnings you hear and read about are true. Besides lung and heart problems, tobacco can cause oral cancer. Of all cancers, 2.4 percent occur in the mouth and tobacco use has been estimated to account for over 90 percent of cancers of the oral cavity and pharynx.* If you are using tobacco and notice any changes in your mouth, contact your doctor immediately.
Wear a mouth guard for any sport or activity in which your mouth can be hit.
Buckle up in the car. A seat belt and shoulder harness can keep your face from striking the steering wheel, the dashboard or windshield during minor accidents.
Quiz on Eating DisordersYou (or a friend) may have an eating disorder if you answer YES to the following questions:
Do you weigh yourself more than once a day?
Are you obsessed with being very thin, even while you are below a normal weight?
Do you have a fear of not being able to stop eating?
Do you vomit after a meal – or have the urge to do so?
(For females only) Have you missed three consecutive menstrual periods?
All eating disorders have health risks. The worst cases can lead to death. Eating disorders associated with vomiting can damage the teeth because of stomach acid. If you suspect you have an eating disorder, please see your doctor as soon as possible.
Tips For Smart Snacking
Be careful of between-meal snacks.
Clear the snack from the teeth as soon as possible. Even a simple swish and rinse with water will help.
Do not let snacks take the place of nutritionally balanced meals.
How Your Pediatric Dentist Can HelpThere are many things a pediatric dentist can do to help assure your oral health for a lifetime. Preventive dentistry techniques such as tooth cleanings, sealants and fluoride treatments are just as important as ever for you. Tips on flossing and brushing, and ideas on snacking and choosing a healthy diet, are available to you from your pediatric dentist and staff as well.
Your pediatric dentist will be glad to talk to you about how your teeth look. If you feel your teeth are too dark, there are techniques now to whiten them. If you have broken teeth, teeth with defects or spaces between your teeth, there are a number of esthetic dentistry techniques to help you look better.
If you are concerned about your bite, crooked teeth or the appearance of your smile, your pediatric dentist can give you advice about correcting such problems.
During your teen years, your wisdom teeth (third molars) will be developing. Although some third molars come into the mouth normally, others need to be removed because of poor position and lack of space. Your pediatric dentist will make sure the proper treatment is prescribed at the right time.
Dentistry for adolescents and teens is a fundamental part of the advanced training of the pediatric dentist. Your dental health and appearance are as important to you and your pediatric dentist. Let us keep your smile sparkling and healthy.
Your pediatric dentist and the American Academy of Pediatric Dentistry hope this brochure is useful to you. Please share this information with a family member or friend.
What are tooth-colored fillings?
Q: What are tooth-colored fillings?
A: Tooth-colored fillings are made from durable plastics called composite resins. Similar in color and texture to natural teeth, the fillings are less noticeable, and much more attractive, than other types of fillings.
Q: What are the advantages of tooth-colored fillings?
A: Because composite resins are tooth-colored, they look more natural than other filling materials. Your child can smile, talk, and eat with confidence. In addition, tooth-colored fillings are compatible with dental sealants. A tooth can be filled and sealed at the same time to prevent further decay.
Q: What are disadvantages?
A: First, tooth-colored fillings are not for every tooth. They work best in small restorations and low-stress areas. For example, your pediatric dentist may not recommend a tooth-colored filling for a large cavity or for the chewing surface of a back tooth. Second, tooth-colored fillings may cost a bit more than silver fillings because they take longer to place.
Q: How do I decide if tooth-colored fillings are right for my child?
A: Talk to your pediatric dentist. Together you will decide what type of filling is best for your child.
Q: How do I care for a tooth-colored filling?
A: Take care of a tooth-colored filling the same way you take care of a silver filling: Brush, floss, and visit your dentist. Any filling will last longer with good oral hygiene. Your pediatric dentist will regularly check the fillings for color change, leakage, or unusual wear and inform you of the need for repair or replacement.
A: Tooth-colored fillings are made from durable plastics called composite resins. Similar in color and texture to natural teeth, the fillings are less noticeable, and much more attractive, than other types of fillings.
Q: What are the advantages of tooth-colored fillings?
A: Because composite resins are tooth-colored, they look more natural than other filling materials. Your child can smile, talk, and eat with confidence. In addition, tooth-colored fillings are compatible with dental sealants. A tooth can be filled and sealed at the same time to prevent further decay.
Q: What are disadvantages?
A: First, tooth-colored fillings are not for every tooth. They work best in small restorations and low-stress areas. For example, your pediatric dentist may not recommend a tooth-colored filling for a large cavity or for the chewing surface of a back tooth. Second, tooth-colored fillings may cost a bit more than silver fillings because they take longer to place.
Q: How do I decide if tooth-colored fillings are right for my child?
A: Talk to your pediatric dentist. Together you will decide what type of filling is best for your child.
Q: How do I care for a tooth-colored filling?
A: Take care of a tooth-colored filling the same way you take care of a silver filling: Brush, floss, and visit your dentist. Any filling will last longer with good oral hygiene. Your pediatric dentist will regularly check the fillings for color change, leakage, or unusual wear and inform you of the need for repair or replacement.
What are tooth-colored fillings?
Q: What are tooth-colored fillings?
A: Tooth-colored fillings are made from durable plastics called composite resins. Similar in color and texture to natural teeth, the fillings are less noticeable, and much more attractive, than other types of fillings.
A: Tooth-colored fillings are made from durable plastics called composite resins. Similar in color and texture to natural teeth, the fillings are less noticeable, and much more attractive, than other types of fillings.
Q: What are the advantages of tooth-colored fillings?
A: Because composite resins are tooth-colored, they look more natural than other filling materials. Your child can smile, talk, and eat with confidence. In addition, tooth-colored fillings are compatible with dental sealants. A tooth can be filled and sealed at the same time to prevent further decay.
A: Because composite resins are tooth-colored, they look more natural than other filling materials. Your child can smile, talk, and eat with confidence. In addition, tooth-colored fillings are compatible with dental sealants. A tooth can be filled and sealed at the same time to prevent further decay.
Q: What are disadvantages?
A: First, tooth-colored fillings are not for every tooth. They work best in small restorations and low-stress areas. For example, your pediatric dentist may not recommend a tooth-colored filling for a large cavity or for the chewing surface of a back tooth. Second, tooth-colored fillings may cost a bit more than silver fillings because they take longer to place.
A: First, tooth-colored fillings are not for every tooth. They work best in small restorations and low-stress areas. For example, your pediatric dentist may not recommend a tooth-colored filling for a large cavity or for the chewing surface of a back tooth. Second, tooth-colored fillings may cost a bit more than silver fillings because they take longer to place.
Q: How do I decide if tooth-colored fillings are right for my child?
A: Talk to your pediatric dentist. Together you will decide what type of filling is best for your child.
A: Talk to your pediatric dentist. Together you will decide what type of filling is best for your child.
Q: How do I care for a tooth-colored filling?
A: Take care of a tooth-colored filling the same way you take care of a silver filling: Brush, floss, and visit your dentist. Any filling will last longer with good oral hygiene. Your pediatric dentist will regularly check the fillings for color change, leakage, or unusual wear and inform you of the need for repair or replacement.
A: Take care of a tooth-colored filling the same way you take care of a silver filling: Brush, floss, and visit your dentist. Any filling will last longer with good oral hygiene. Your pediatric dentist will regularly check the fillings for color change, leakage, or unusual wear and inform you of the need for repair or replacement.
What is Malocclusion?
Q: What is malocclusion?
Malocclusion is the improper positioning of the teeth and jaws. It is a variation of normal growth and development which can affect the bite, the ability to clean teeth properly, gum tissue health, jaw growth, speech development and appearance.
Q: What causes malocclusion?
Both heredity and environmental factors can play a role in developing malocclusions. The shape and size of the face, jaws and teeth are determined mostly by inheritance. Environmental factors can also have a large impact and these are the types of problems which the pediatric dentist is well trained to manage.
Q: How long does it take to treat a malocclusion?
Every child is unique and must be treated individually. The pediatric dentist will provide an estimate of the length of time required prior to initiating treatment. In complex malocclusions the treatment may be divided into several phases which are scheduled to coincide with the child's particular pattern of growth and development.
Q: Is it necessary to remove healthy teeth to correct a malocclusion?
Carefully controlled removal of selected primary teeth may be necessary to guide the permanent teeth into proper position. This procedure requires frequent monitoring over a period of time and usually in combination with the use of some type of appliance. The removal of permanent teeth depends specifically upon the circumstances for that particular child. There are some malocclusions which cannot be treated successfully without removing permanent teeth and there are other situations where permanent teeth should definitely not be removed. This is a decision which must be made very carefully after thoroughly evaluating all of the diagnostic materials available for that patient.
Q: What information does the pediatric dentist need to evaluate a developing malocclusion?
The complexity of each child's individual problem will dictate the extent of examination and diagnostic procedures. Following a thorough clinical examination with a review of past medical and dental history, impressions of the teeth are taken from which plaster models are made. These study models provide a baseline reference of the current relationship of the teeth and jaws and also provide a method to monitor the progress of any treatment. Photographs of the face and teeth also provide a record of the child's facial appearance prior to treatment. Several types of X-rays may be needed to properly diagnose a developing malocclusion. Most commonly used are a panoramic X-ray, which shows all the upper and lower teeth in biting position as well as any teeth still developing within the jaws, and a lateral X-ray of the entire head, known as a cephalometric X-ray which shows the relationship of the teeth and jaws to the face and skull.
Q: What types of appliances are used to correct malocclusion?
There are two basic types of tooth movement appliances, removable and fixed. Removable appliances are made of wires and plastic and can be removed from the mouth by the patient. Some fit the upper and lower teeth at the same time. Their success is totally dependent on the patient's compliance in wearing the appliance exactly as instructed by the pediatric dentist. An advantage of removable appliances is that they are easy to keep clean. Fixed appliances are what we know as "braces." Because this type of appliance is attached directly to the teeth, there is better control of tooth movement. However, cooperation from the patient in maintaining scrupulous oral hygiene while wearing fixed appliances is essential in preventing cavities in areas where food collects easily around these appliances.
Malocclusion is the improper positioning of the teeth and jaws. It is a variation of normal growth and development which can affect the bite, the ability to clean teeth properly, gum tissue health, jaw growth, speech development and appearance.
Q: What causes malocclusion?
Both heredity and environmental factors can play a role in developing malocclusions. The shape and size of the face, jaws and teeth are determined mostly by inheritance. Environmental factors can also have a large impact and these are the types of problems which the pediatric dentist is well trained to manage.
Q: How long does it take to treat a malocclusion?
Every child is unique and must be treated individually. The pediatric dentist will provide an estimate of the length of time required prior to initiating treatment. In complex malocclusions the treatment may be divided into several phases which are scheduled to coincide with the child's particular pattern of growth and development.
Q: Is it necessary to remove healthy teeth to correct a malocclusion?
Carefully controlled removal of selected primary teeth may be necessary to guide the permanent teeth into proper position. This procedure requires frequent monitoring over a period of time and usually in combination with the use of some type of appliance. The removal of permanent teeth depends specifically upon the circumstances for that particular child. There are some malocclusions which cannot be treated successfully without removing permanent teeth and there are other situations where permanent teeth should definitely not be removed. This is a decision which must be made very carefully after thoroughly evaluating all of the diagnostic materials available for that patient.
Q: What information does the pediatric dentist need to evaluate a developing malocclusion?
The complexity of each child's individual problem will dictate the extent of examination and diagnostic procedures. Following a thorough clinical examination with a review of past medical and dental history, impressions of the teeth are taken from which plaster models are made. These study models provide a baseline reference of the current relationship of the teeth and jaws and also provide a method to monitor the progress of any treatment. Photographs of the face and teeth also provide a record of the child's facial appearance prior to treatment. Several types of X-rays may be needed to properly diagnose a developing malocclusion. Most commonly used are a panoramic X-ray, which shows all the upper and lower teeth in biting position as well as any teeth still developing within the jaws, and a lateral X-ray of the entire head, known as a cephalometric X-ray which shows the relationship of the teeth and jaws to the face and skull.
Q: What types of appliances are used to correct malocclusion?
There are two basic types of tooth movement appliances, removable and fixed. Removable appliances are made of wires and plastic and can be removed from the mouth by the patient. Some fit the upper and lower teeth at the same time. Their success is totally dependent on the patient's compliance in wearing the appliance exactly as instructed by the pediatric dentist. An advantage of removable appliances is that they are easy to keep clean. Fixed appliances are what we know as "braces." Because this type of appliance is attached directly to the teeth, there is better control of tooth movement. However, cooperation from the patient in maintaining scrupulous oral hygiene while wearing fixed appliances is essential in preventing cavities in areas where food collects easily around these appliances.
What is Malocclusion?
Q: What is malocclusion?
Malocclusion is the improper positioning of the teeth and jaws. It is a variation of normal growth and development which can affect the bite, the ability to clean teeth properly, gum tissue health, jaw growth, speech development and appearance.
Malocclusion is the improper positioning of the teeth and jaws. It is a variation of normal growth and development which can affect the bite, the ability to clean teeth properly, gum tissue health, jaw growth, speech development and appearance.
Q: What causes malocclusion?
Both heredity and environmental factors can play a role in developing malocclusions. The shape and size of the face, jaws and teeth are determined mostly by inheritance. Environmental factors can also have a large impact and these are the types of problems which the pediatric dentist is well trained to manage.
Both heredity and environmental factors can play a role in developing malocclusions. The shape and size of the face, jaws and teeth are determined mostly by inheritance. Environmental factors can also have a large impact and these are the types of problems which the pediatric dentist is well trained to manage.
Q: How long does it take to treat a malocclusion?
Every child is unique and must be treated individually. The pediatric dentist will provide an estimate of the length of time required prior to initiating treatment. In complex malocclusions the treatment may be divided into several phases which are scheduled to coincide with the child's particular pattern of growth and development.
Every child is unique and must be treated individually. The pediatric dentist will provide an estimate of the length of time required prior to initiating treatment. In complex malocclusions the treatment may be divided into several phases which are scheduled to coincide with the child's particular pattern of growth and development.
Q: Is it necessary to remove healthy teeth to correct a malocclusion?
Carefully controlled removal of selected primary teeth may be necessary to guide the permanent teeth into proper position. This procedure requires frequent monitoring over a period of time and usually in combination with the use of some type of appliance. The removal of permanent teeth depends specifically upon the circumstances for that particular child. There are some malocclusions which cannot be treated successfully without removing permanent teeth and there are other situations where permanent teeth should definitely not be removed. This is a decision which must be made very carefully after thoroughly evaluating all of the diagnostic materials available for that patient.
Carefully controlled removal of selected primary teeth may be necessary to guide the permanent teeth into proper position. This procedure requires frequent monitoring over a period of time and usually in combination with the use of some type of appliance. The removal of permanent teeth depends specifically upon the circumstances for that particular child. There are some malocclusions which cannot be treated successfully without removing permanent teeth and there are other situations where permanent teeth should definitely not be removed. This is a decision which must be made very carefully after thoroughly evaluating all of the diagnostic materials available for that patient.
Q: What information does the pediatric dentist need to evaluate a developing malocclusion?
The complexity of each child's individual problem will dictate the extent of examination and diagnostic procedures. Following a thorough clinical examination with a review of past medical and dental history, impressions of the teeth are taken from which plaster models are made. These study models provide a baseline reference of the current relationship of the teeth and jaws and also provide a method to monitor the progress of any treatment. Photographs of the face and teeth also provide a record of the child's facial appearance prior to treatment. Several types of X-rays may be needed to properly diagnose a developing malocclusion. Most commonly used are a panoramic X-ray, which shows all the upper and lower teeth in biting position as well as any teeth still developing within the jaws, and a lateral X-ray of the entire head, known as a cephalometric X-ray which shows the relationship of the teeth and jaws to the face and skull.
The complexity of each child's individual problem will dictate the extent of examination and diagnostic procedures. Following a thorough clinical examination with a review of past medical and dental history, impressions of the teeth are taken from which plaster models are made. These study models provide a baseline reference of the current relationship of the teeth and jaws and also provide a method to monitor the progress of any treatment. Photographs of the face and teeth also provide a record of the child's facial appearance prior to treatment. Several types of X-rays may be needed to properly diagnose a developing malocclusion. Most commonly used are a panoramic X-ray, which shows all the upper and lower teeth in biting position as well as any teeth still developing within the jaws, and a lateral X-ray of the entire head, known as a cephalometric X-ray which shows the relationship of the teeth and jaws to the face and skull.
Q: What types of appliances are used to correct malocclusion?
There are two basic types of tooth movement appliances, removable and fixed. Removable appliances are made of wires and plastic and can be removed from the mouth by the patient. Some fit the upper and lower teeth at the same time. Their success is totally dependent on the patient's compliance in wearing the appliance exactly as instructed by the pediatric dentist. An advantage of removable appliances is that they are easy to keep clean. Fixed appliances are what we know as "braces." Because this type of appliance is attached directly to the teeth, there is better control of tooth movement. However, cooperation from the patient in maintaining scrupulous oral hygiene while wearing fixed appliances is essential in preventing cavities in areas where food collects easily around these appliances.
There are two basic types of tooth movement appliances, removable and fixed. Removable appliances are made of wires and plastic and can be removed from the mouth by the patient. Some fit the upper and lower teeth at the same time. Their success is totally dependent on the patient's compliance in wearing the appliance exactly as instructed by the pediatric dentist. An advantage of removable appliances is that they are easy to keep clean. Fixed appliances are what we know as "braces." Because this type of appliance is attached directly to the teeth, there is better control of tooth movement. However, cooperation from the patient in maintaining scrupulous oral hygiene while wearing fixed appliances is essential in preventing cavities in areas where food collects easily around these appliances.
Wednesday, December 17, 2008
X-Ray Use and Safety
Q: How often should a child have dental X-ray films?
A: Since every child is unique, the need for dental X-ray films varies from child to child. Films are taken only after a complete review of your child's health, and only when they are likely to yield information that a visual exam cannot.
In general, children need X-rays more often than adults. Their mouths grow and change rapidly. They are more susceptible to tooth decay than adults. The American Academy of Pediatric Dentistry recommends X-ray examinations every six months for children with a high risk of tooth decay. Children with a low risk of tooth decay require X-rays less frequently.
Q: Why should X-ray films be taken if my child has never had a cavity?
A: X-ray films detect much more than cavities. For example, X-rays may be needed to survey erupting teeth, diagnose bone diseases, evaluate the results of an injury, or plan orthodontic treatment. X-rays allow dentists to diagnose and treat health conditions that cannot be detected during a clinical examination. If dental problems are found and treated early, dental care is more comfortable and affordable.
Q: Will X-ray films be taken routinely?
A: No. X-ray films are recommended only when necessary to protect your child's dental health. The frequency of X-ray films is determined by your child's individual needs.
Q: How will my child be protected from X-ray exposure?
A: Lead body aprons and shields will protect your child. Today's equipment filters out unnecessary X-rays and restricts the X-ray beam to the area of interest. High-speed film and proper shielding assure that your child receives a minimal amount of radiation exposure
A: Since every child is unique, the need for dental X-ray films varies from child to child. Films are taken only after a complete review of your child's health, and only when they are likely to yield information that a visual exam cannot.
In general, children need X-rays more often than adults. Their mouths grow and change rapidly. They are more susceptible to tooth decay than adults. The American Academy of Pediatric Dentistry recommends X-ray examinations every six months for children with a high risk of tooth decay. Children with a low risk of tooth decay require X-rays less frequently.
Q: Why should X-ray films be taken if my child has never had a cavity?
A: X-ray films detect much more than cavities. For example, X-rays may be needed to survey erupting teeth, diagnose bone diseases, evaluate the results of an injury, or plan orthodontic treatment. X-rays allow dentists to diagnose and treat health conditions that cannot be detected during a clinical examination. If dental problems are found and treated early, dental care is more comfortable and affordable.
Q: Will X-ray films be taken routinely?
A: No. X-ray films are recommended only when necessary to protect your child's dental health. The frequency of X-ray films is determined by your child's individual needs.
Q: How will my child be protected from X-ray exposure?
A: Lead body aprons and shields will protect your child. Today's equipment filters out unnecessary X-rays and restricts the X-ray beam to the area of interest. High-speed film and proper shielding assure that your child receives a minimal amount of radiation exposure
Oral Health Initiative
The purpose of this training is to provide a concise overview of how to perform an oral examination and conduct an oral health risk assessment and triage for infants and young children. According to the Centers for Disease Control and Prevention, dental caries are the most prevalent infectious disease among US children. More than 40% of children have tooth decay by the time they reach kindergarten, and more than 52 million hours of school are lost each year because of dental problems, as cited by the US Department of Health and Human Services. Pediatricians can play an important role in children’s oral health outcomes, particularly since they typically see young children early and often. With proper training in how to perform an oral examination and how to conduct an oral health risk assessment, pediatricians and other health care professionals can minimize in children serious health consequences that include a higher risk of new carious lesions, hospitalizations and emergency room visits, delayed or insufficient physical development, loss of school days, and a diminished ability to learn. In addition, a child’s primary care physician is a key resource to families when racial, ethnic, socioeconomic or educational disparities create barriers to the child receiving regular dental care. This training is based on the AAP policy statement, “Oral Health Risk Assessment Timing and Establishment of the Dental Home.” Although general information about oral health disease in children will be presented in the training, the primary focus will be on early childhood dental caries, seen in children aged 0 to 3 years. You should participate in this training if you are a(n):
Primary care pediatrician
Family physician
Resident in pediatrics or family practice
Allied health professional in a pediatric or family practice office (eg, nurse, nurse practitioner, physician assistant
Any health care provider treating children in rural or underserved communities, where pediatric dental care is more restrictedThis training is best viewed with a 5.0 or higher version of Internet Explorer version and a monitor display of at least 800 x 600 pixels. To download a PowerPoint version of this presentation, click here
Primary care pediatrician
Family physician
Resident in pediatrics or family practice
Allied health professional in a pediatric or family practice office (eg, nurse, nurse practitioner, physician assistant
Any health care provider treating children in rural or underserved communities, where pediatric dental care is more restrictedThis training is best viewed with a 5.0 or higher version of Internet Explorer version and a monitor display of at least 800 x 600 pixels. To download a PowerPoint version of this presentation, click here
Columbia University
Columbia University College of Dental Medicine (CDM) was established in 1916 as the School of Dental and Oral Surgery, when the School became incorporated into Columbia University. The College’s mission has evolved into a tripartite commitment to education, patient care, and research.
The mission of the College of Dental Medicine is to train general dentists, dental specialists, and dental assistants in a setting that emphasizes comprehensive dental care delivery and stimulates professional growth; inspire, support, and promote faculty, pre- and postdoctoral student, and hospital resident participation in research to advance the professional knowledge base; and
provide comprehensive dental care for the underserved community of northern Manhattan.
Education Goals
The curriculum strives to prepare graduates who, in addition to becoming competent general dentists and dental specialists, are able to provide comprehensive care to all, including medically complex patients, and are prepared to function as integral members of a health care team. This is achieved by virtue of a strong foundation in the biomedical sciences as well as a curricular emphasis on the social, economic, and ethical aspects of the profession.
The College is committed to providing its students with a rich and diverse clinical education experience, by improving the oral health of and bringing clinical services to underserved and minority patients of northern Manhattan.
CDM provides an academic environment that encourages students to take advantage of the educational opportunities that the University offers in such diverse areas as public health, informatics, and biomedical research, thereby enriching the education of those who will enter the practice of dentistry and the dental specialties.
The education goals of the College of Dental Medicine are to
prepare students to become competent in general dentistry;
prepare students for careers in dentistry with a strong emphasis in the biomedical sciences;
prepare students with an understanding of the social, economic, and ethical aspects of the profession, as well as the historical foundations of dentistry; and support and strengthen advanced dental education programs in general dentistry, the dental specialties, and the dental sciences.
Research Goals
Research is the mechanism by which we expand our existing knowledge base. Dentistry has always been, and continues to be, an evolving health care discipline whose foundations are based on research. CDM is committed to inspire and support future dental educators who are committed to research as part of their professional lives; to foster and promote faculty, pre and postdoctoral student, and hospital resident participation in research; and to train students and residents in research methodology. This training will allow the future generations of practitioners to interpret new research findings in the literature and, when possible, to incorporate this information into the clinical practice of dentistry.
The research goals of the College of Dental Medicine are to
encourage and support all forms of academic research;
promote collaborative research activities between faculty at the College and faculty in the Health Sciences and the University;
promote pre- and postdoctoral students’ research training; and develop dental educators committed to research as part of their professional lives.
Patient Care Goals
The College is the largest primary and specialty oral health care provider in the northern Manhattan communities of Harlem and Washington Heights/Inwood. Both communities have been designated dental health professional manpower shortage areas by the Department of Health and Human Services’ Bureau of Primary Care. Patient care is a primary College mission and the College strives to meet the needs of these underserved communities.
The patient care goals of the College of Dental Medicine are to view patient care as a primary College commitment and to deliver comprehensive and quality care while providing a rich, diverse clinical education experience to students; and bring clinical services to a wide range of underserved and minority patients in northern Manhattan.
The mission of the College of Dental Medicine is to train general dentists, dental specialists, and dental assistants in a setting that emphasizes comprehensive dental care delivery and stimulates professional growth; inspire, support, and promote faculty, pre- and postdoctoral student, and hospital resident participation in research to advance the professional knowledge base; and
provide comprehensive dental care for the underserved community of northern Manhattan.
Education Goals
The curriculum strives to prepare graduates who, in addition to becoming competent general dentists and dental specialists, are able to provide comprehensive care to all, including medically complex patients, and are prepared to function as integral members of a health care team. This is achieved by virtue of a strong foundation in the biomedical sciences as well as a curricular emphasis on the social, economic, and ethical aspects of the profession.
The College is committed to providing its students with a rich and diverse clinical education experience, by improving the oral health of and bringing clinical services to underserved and minority patients of northern Manhattan.
CDM provides an academic environment that encourages students to take advantage of the educational opportunities that the University offers in such diverse areas as public health, informatics, and biomedical research, thereby enriching the education of those who will enter the practice of dentistry and the dental specialties.
The education goals of the College of Dental Medicine are to
prepare students to become competent in general dentistry;
prepare students for careers in dentistry with a strong emphasis in the biomedical sciences;
prepare students with an understanding of the social, economic, and ethical aspects of the profession, as well as the historical foundations of dentistry; and support and strengthen advanced dental education programs in general dentistry, the dental specialties, and the dental sciences.
Research Goals
Research is the mechanism by which we expand our existing knowledge base. Dentistry has always been, and continues to be, an evolving health care discipline whose foundations are based on research. CDM is committed to inspire and support future dental educators who are committed to research as part of their professional lives; to foster and promote faculty, pre and postdoctoral student, and hospital resident participation in research; and to train students and residents in research methodology. This training will allow the future generations of practitioners to interpret new research findings in the literature and, when possible, to incorporate this information into the clinical practice of dentistry.
The research goals of the College of Dental Medicine are to
encourage and support all forms of academic research;
promote collaborative research activities between faculty at the College and faculty in the Health Sciences and the University;
promote pre- and postdoctoral students’ research training; and develop dental educators committed to research as part of their professional lives.
Patient Care Goals
The College is the largest primary and specialty oral health care provider in the northern Manhattan communities of Harlem and Washington Heights/Inwood. Both communities have been designated dental health professional manpower shortage areas by the Department of Health and Human Services’ Bureau of Primary Care. Patient care is a primary College mission and the College strives to meet the needs of these underserved communities.
The patient care goals of the College of Dental Medicine are to view patient care as a primary College commitment and to deliver comprehensive and quality care while providing a rich, diverse clinical education experience to students; and bring clinical services to a wide range of underserved and minority patients in northern Manhattan.
Tuesday, December 16, 2008
How to become a pediatric dentist
It's a long road but worth it.
First of all gather all the information about the programs that are related to pediatric dentistry courses. For the relevant information you can collect the brochures or use other local media of information to locate the schools which have the facility of pediatric dentistry. You can also browse on the net to get all the relevant information. You can contact the pediatric dentists to get proper career advice and gather all the information about the special work efficiency that is required in this field.
Next you have to acquire a Bachelor’s degree in Science. Though you do not need any specified major, you should have good knowledge about Biology and Mathematics curriculum to qualify the entrance examination for admission in the dental course. It will also help you while you will be studying in the dental school as it will be a part of your curriculum. You can also avail the facility of the programs that allow the under graduate students to get admission in the dental school and study the prescribed curriculum for pre dental course and get the Bachelor’s degree in Science.
After graduating from the dental school you will be awarded the degree of dental surgery or medical dentistry as per the decision of the school. The next step is to obtain specialization in pediatric dentistry which you can attain by doing a two to three year residency in pediatric dentistry.
To enter into the profession you have to obtain the license by passing the exam that is conducted by the state. To get the specification about the course for the exam and the preparation mode you can contact the state board that deals with dentistry. After you get the license apply for the residency in pediatric dentistry which will be for two to three years.
The last step is to look for the position of pediatric dentist. You can choose the place of according to your convenience that is you can either work in a clinic or a hospital or you can start your own private practice.
First of all gather all the information about the programs that are related to pediatric dentistry courses. For the relevant information you can collect the brochures or use other local media of information to locate the schools which have the facility of pediatric dentistry. You can also browse on the net to get all the relevant information. You can contact the pediatric dentists to get proper career advice and gather all the information about the special work efficiency that is required in this field.
Next you have to acquire a Bachelor’s degree in Science. Though you do not need any specified major, you should have good knowledge about Biology and Mathematics curriculum to qualify the entrance examination for admission in the dental course. It will also help you while you will be studying in the dental school as it will be a part of your curriculum. You can also avail the facility of the programs that allow the under graduate students to get admission in the dental school and study the prescribed curriculum for pre dental course and get the Bachelor’s degree in Science.
After graduating from the dental school you will be awarded the degree of dental surgery or medical dentistry as per the decision of the school. The next step is to obtain specialization in pediatric dentistry which you can attain by doing a two to three year residency in pediatric dentistry.
To enter into the profession you have to obtain the license by passing the exam that is conducted by the state. To get the specification about the course for the exam and the preparation mode you can contact the state board that deals with dentistry. After you get the license apply for the residency in pediatric dentistry which will be for two to three years.
The last step is to look for the position of pediatric dentist. You can choose the place of according to your convenience that is you can either work in a clinic or a hospital or you can start your own private practice.
AAPD Fluoride
The American Academy of Pediatric Dentistry (AAPD), affirming
that fluoride is a safe and effective adjunct in reducing the
risk of caries and reversing enamel demineralization, encourages
public health officials, health care providers, and parents/caregivers
to optimize fluoride exposure.
The adjustment of the fluoride level in community water supplies
to optimal concentration is the most beneficial and inexpensive
method of reducing the occurrence of caries.1 Epidemiologic
data within the last half-century indicate reductions in caries of
55 to 60% and recent data still shows caries reduction of approximately
25%, without significant enamel fluorosis, when domestic
water supplies are fluoridated at an optimal level.2 Evidence
accumulated from long-term use of fluorides has demonstrated
that the cost of oral health care for children can be reduced by as
much as 50%.3 These savings in health dollars accrue to private
individuals, group purchasers, and government care programs.
An even higher caries reduction can be obtained if the proper
use of fluorides is combined with other dietary, oral hygiene, and
preventive measures4,5 as prescribed by a dentist familiar with the
child’s oral health and family history.
A large body of literature supports the incorporation
of optimal fluoride levels in drinking water supplies. When
fluoridation of drinking water is impossible, effective systemic
fluoridation can be achieved through the intake of daily fluoride
supplements. Before supplements are prescribed, it is essential to
review dietary sources of fluoride (eg, all drinking water sources,
consumed beverages, prepared food, toothpaste) to determine
the patient’s true exposure to fluoride.1,6-9 Fluoride content
of ready to use infant formulas in the US and Canada ranges
from 0.1 to 0.3 mg/L10, which provides only a modest source of
fluoride. Non-milk based formulas have higher fluoride content
because the calcium that is added to formula contains fluoride.
The more important issue, however, is the fluoride content of
concentrated or powdered formula when reconstituted with
fluoridated water. Considering the potential for mild fluorosis,
caution is advised for infants consuming formula that is reconstituted
with optimally-fluoridated water.
Significant cariostatic benefits can be achieved by the use of
fluoride-containing preparations such as toothpastes, gels, and
rinses, especially in areas without water fluoridation.11 Monitoring
children’s use of topical fluoride-containing products, including
toothpaste, may prevent ingestion of excessive amounts of
fluoride.12
A number of clinical trials have confirmed the anticaries
effect of professional topical fluoride treatments, including
5% neutral sodium fluoride varnish.13,14 Fluoride varnishes can
prevent or reverse enamel demineralization.15 In children with
moderate to high caries risk, fluoride varnishes14,16 and fluoridereleasing
restorative and bonding materials have been shown to
be beneficial and are best utilized as part of a comprehensive
preventive program in the dental home.
that fluoride is a safe and effective adjunct in reducing the
risk of caries and reversing enamel demineralization, encourages
public health officials, health care providers, and parents/caregivers
to optimize fluoride exposure.
The adjustment of the fluoride level in community water supplies
to optimal concentration is the most beneficial and inexpensive
method of reducing the occurrence of caries.1 Epidemiologic
data within the last half-century indicate reductions in caries of
55 to 60% and recent data still shows caries reduction of approximately
25%, without significant enamel fluorosis, when domestic
water supplies are fluoridated at an optimal level.2 Evidence
accumulated from long-term use of fluorides has demonstrated
that the cost of oral health care for children can be reduced by as
much as 50%.3 These savings in health dollars accrue to private
individuals, group purchasers, and government care programs.
An even higher caries reduction can be obtained if the proper
use of fluorides is combined with other dietary, oral hygiene, and
preventive measures4,5 as prescribed by a dentist familiar with the
child’s oral health and family history.
A large body of literature supports the incorporation
of optimal fluoride levels in drinking water supplies. When
fluoridation of drinking water is impossible, effective systemic
fluoridation can be achieved through the intake of daily fluoride
supplements. Before supplements are prescribed, it is essential to
review dietary sources of fluoride (eg, all drinking water sources,
consumed beverages, prepared food, toothpaste) to determine
the patient’s true exposure to fluoride.1,6-9 Fluoride content
of ready to use infant formulas in the US and Canada ranges
from 0.1 to 0.3 mg/L10, which provides only a modest source of
fluoride. Non-milk based formulas have higher fluoride content
because the calcium that is added to formula contains fluoride.
The more important issue, however, is the fluoride content of
concentrated or powdered formula when reconstituted with
fluoridated water. Considering the potential for mild fluorosis,
caution is advised for infants consuming formula that is reconstituted
with optimally-fluoridated water.
Significant cariostatic benefits can be achieved by the use of
fluoride-containing preparations such as toothpastes, gels, and
rinses, especially in areas without water fluoridation.11 Monitoring
children’s use of topical fluoride-containing products, including
toothpaste, may prevent ingestion of excessive amounts of
fluoride.12
A number of clinical trials have confirmed the anticaries
effect of professional topical fluoride treatments, including
5% neutral sodium fluoride varnish.13,14 Fluoride varnishes can
prevent or reverse enamel demineralization.15 In children with
moderate to high caries risk, fluoride varnishes14,16 and fluoridereleasing
restorative and bonding materials have been shown to
be beneficial and are best utilized as part of a comprehensive
preventive program in the dental home.
AAPD Definitions
Dental Home
The dental home is the ongoing relationship between the dentist
and the patient, inclusive of all aspects of oral health care delivered
in a comprehensive, continuously accessible, coordinated, and
family-centered way. Establishment of a dental home begins no
later than 12 months of age and includes referral to dental specialists
when appropriate.
Dental Neglect
Dental caries, periodontal diseases, and other oral conditions,if left untreated, can lead to pain, infection, and loss of function.These undesirable outcomes can adversely affect learning,communication, nutrition, and other activities necessary fornormal growth and development.Dental neglect is willful failure of parent or guardian to seekand follow through with treatment necessary to ensure a levelof oral heath essential for adequate function and freedom frompain and infection.
Dental Disability
Dental caries, periodontal disease, dentoalveolar trauma, and
other oral conditions left untreated can limit substantially a
child’s development and an individual’s participation in life
activities. An Individual should be considered to have a dental
disability if pain, infection, or lack of stable and functional
dentition:
1. restricts nutritional intake adequate for growth and energy
needs;
2. delays or otherwise alters growth and development;
3. inhibits participation in life activities; or
4. diminishes quality of life.
The dental home is the ongoing relationship between the dentist
and the patient, inclusive of all aspects of oral health care delivered
in a comprehensive, continuously accessible, coordinated, and
family-centered way. Establishment of a dental home begins no
later than 12 months of age and includes referral to dental specialists
when appropriate.
Dental Neglect
Dental caries, periodontal diseases, and other oral conditions,if left untreated, can lead to pain, infection, and loss of function.These undesirable outcomes can adversely affect learning,communication, nutrition, and other activities necessary fornormal growth and development.Dental neglect is willful failure of parent or guardian to seekand follow through with treatment necessary to ensure a levelof oral heath essential for adequate function and freedom frompain and infection.
Dental Disability
Dental caries, periodontal disease, dentoalveolar trauma, and
other oral conditions left untreated can limit substantially a
child’s development and an individual’s participation in life
activities. An Individual should be considered to have a dental
disability if pain, infection, or lack of stable and functional
dentition:
1. restricts nutritional intake adequate for growth and energy
needs;
2. delays or otherwise alters growth and development;
3. inhibits participation in life activities; or
4. diminishes quality of life.
Sedation Dentistry
Sedation dentistry refers to the use of sedation during dental treatment. Sedation is most commonly used during extensive procedures, for patients with dental phobia or for patients who find it difficult to sit still. There are different types of sedation, including nitrous oxide ("laughing gas"), IV sedation, oral sedatives and general anesthetic.
Sedation
Sedation can range from the use of nitrous oxide to calm a patient to general anesthetics used to put patients to sleep. Patients with dental phobia, low pain tolerance, major dental treatment, physical handicaps or strong gag reflexes may require sedation. Procedures like fillings, crowns, root canals, extractions, cosmetic procedures and periodontal treatments often require sedation.
Sedation is endorsed by the American Dental Association and is an effective way to make many patients comfortable during their dental visit. Before using a sedative or anesthetic, it is important to tell your dentist about any medications or medical treatments your child is receiving. Before administering any sedative or anesthetic, your dentist will talk to you about the process of sedation and pre- and post-sedation instructions.
"Laughing Gas"
Nitrous oxide, more commonly known as laughing gas, is often used as a conscious sedative during a dental visit. The gas is administered with a mixture of oxygen and has a calming effect that helps phobic or anxious patients relax during their dental treatment. Because it is a mild sedative, patients are still conscious and can talk to their dentist during their visit. After treatment, the nitrous is turned off and oxygen is administered for five to 10 minutes to help flush any remaining gas. The effects wear off almost immediately. Nitrous oxide rarely has side effects, although some patients may experience minor nausea and constipation. Your doctor will provide you with pre- and post-sedation instructions.
Below is an article from the Journal of American Dental Association on Oral Conscious Sedation
J Am Dent Assoc, Vol 132, No 11, 1531-1539. © 2001 American Dental Association
RESEARCH
JADA Continuing Education
Adverse events and outcomes of conscious sedation for pediatric patients
Study of an oral sedation regimen
PATTARAWADEE LEELATAWEEDWUD, D.D.S., M.S. and WILLIAM F. VANN JR., D.M.D., M.S., Ph.D.
Background. The authors report on adverse events and sedation outcomes for an oral sedation regimen of chloral hydrate, meperidine and hydroxyzine with 100 percent oxygen, or O2, supplementation.
Methods. In a five-year retrospective study, the authors examined 195 records of conscious sedation performed in 111 healthy children aged 24 to 48 months (mean, 47 months). The authors analyzed age, sex, weight, methods of drug delivery, waiting time after drug administration, treatment rendered, treatment time, adverse events, sedation outcomes and the number of visits needed to complete treatment using descriptive statistics, 2 tests, t test and analysis of variance.
Results. Adverse events—including vomiting, desaturation, prolonged sedation and an apneic event—occurred in 3 percent of all sedations and were minor. Seventy-two percent of sedations had satisfactory behavioral outcomes, 23 percent had unsatisfactory outcomes, and 5 percent of the cases were aborted because of disruptive behavior. Sex was not a significant factor for the success. Patient compliance with drinking medications (P = .013) and a longer waiting time after medication intake (P = .012) yielded better sedation outcomes.
Conclusions. Minimal minor adverse events occurred with this sedation regimen. The success rate was 72 percent. Compliance with taking oral medications and waiting time appeared to be important factors in predicting sedation success.
Clinical Implications. This oral sedation regimen offers reasonable outcomes with minimal adverse events under a strict protocol and use of O2 supplementation. The results also revealed associations that give guidance for case selection and outcome prediction.
For many years, conscious sedation has been a popular pharmacological approach in the management of young uncooperative children who need invasive dental and medical procedures. While conscious sedation is believed to be used widely by general dental practitioners, or GPs, the frequency of its use by them is not well-documented. The published literature, however, does contain several reports that document the frequency with which pediatric dentists use conscious sedation. Davis1 surveyed the members of College of Diplomates of the American Board of Pediatric Dentistry in 1988 and reported that more than 76 percent of respondents used conscious sedation in their practices. In 1989 and 1993, Houpt chronicled the results of two large national surveys on the use of sedative agents by members of the American Academy of Pediatric Dentistry, or AAPD, referred to as Project USAP I2 and Project USAP II.3 The 1,497 respondents in Project USAP II3 reported 33,208 drug administrations for sedation in a three-month period. In 1996, Wilson4 reported the results of a survey that reviewed responses from 1,758 AADP members. Forty percent reported using sedation as frequently as one to five times weekly, and 20 percent reported using sedation more frequently than five times weekly.
An oral sedation of chloral hydrate, meperidine and hydroxyzine pamoate offers reasonable outcomes with minimal adverse events under a strict protocol and use of supplementary oxygen. Practitioners are aware that conscious sedation procedures carry risks from the potential side effects of the medications. For example, nausea and vomiting are not uncommon with sedation agents such as chloral hydrate, meperidine and nitrous oxide.5–7 The most serious adverse outcome of pediatric conscious sedation is respiratory compromise and its related consequences.8–14 Respiratory compromise can lead to hypoxemia and predispose children to a range of deleterious conditions.14
Morbidity and mortality from pediatric conscious sedation have been reported periodically.15–18 Since the publication of Goodson and Moore’s19 1983 article on sedation misadventures, the safety of sedation regimens for children has received considerable scrutiny. In 1985, the emergence of the Guidelines for the Elective Use of Conscious Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients20 elevated the professional standards for the safe provision of sedation of children. Professional discourse on the standards and their subsequent revisions by American Academy of Pediatrics in 199221 and AAPD in 199322 and in 199623 has led to increasing attention on the safety of conscious sedation of children, especially in a dental setting. Even so, conscious sedation for children still appears to carry significant potential for adverse outcomes. Wilson4 noted that of the 1,758 pediatric dentists who responded to his 1996 survey, 30 percent had experienced compromised airways in patients sedated with sedatives and nitrous oxide/oxygen analgesia, and 5 percent noted that they had activated emergency medical services secondary to sedation procedures.
Many drug regimens and routes of administration have been investigated and reported for conscious sedation of children in the dental setting. One regimen that has been the subject of several studies10,12,24,25 is an oral elixir of chloral hydrate (50 milligrams per kilogram), meperidine (1.5 mg/kg) and hydroxyzine pamoate (25 mg). In this context, we will refer to this elixir as the ChMH regimen. Previous studies have reported success rates with this regimen ranging from 60 to 66 percent.24,25
The rationale for ChMH. The rationale for the ChMH regimen is based on its potential for anxiolytic, analgesic and antiemetic effects. Chloral hydrate is a psychotropic agent with anxiolytic, sedative and hypnotic properties.6,26 It has a wide margin of safety and has been studied extensively as a sedative drug for children. It is relatively easy to administer and is well-absorbed orally, requiring approximately 30 to 60 minutes to reach its peak effect.5 Chloral hydrate is the most common sedative agent used in conscious sedation for pediatric dental patients.2,3
Meperidine is a narcotic analgesic with effects similar to, but less potent than, morphine.6 Its therapeutic actions include sedation and analgesia. Meperidine can cause respiratory depression, which can be potentiated by anxiolytic agents such as chloral hydrate. Oral meperidine has a rapid onset of 10 to 15 minutes; however, it requires one to two hours to reach its peak effect.27
Hydroxyzine pamoate is an antihistamine and psychotropic agent that possesses antiemetic, anxiolytic, sedative and hypnotic properties. Oral hydroxyzine is absorbed rapidly with onset within 15 to 30 minutes.28 It has a wide margin of safety and is a popular drug in pediatric conscious sedation.2,3 Hydroxyzine commonly is used as a sole agent or in combination with chloral hydrate and meperidine.26,28 When used as a combination drug with other central nervous system depressants, hydroxyzine can potentiate the central nervous system depression effect.6,28 The antihistamine and antiemetic properties of hydroxyzine are used to overcome the histamine-releasing effect of meperidine, as well as the nausea and vomiting effects of both chloral hydrate and meperidine. The adverse effects of hydroxyzine are mild and transitory in nature.6
Nathan and West24 reported better sedation outcomes by adding meperidine to chloral hydrate and hydroxyzine than with the same regimen without meperidine. Hasty and colleagues10 corroborated this finding and reported that meperidine did not increase the risk of experiencing complications, including respiratory compromise. They attributed the more favorable outcomes to the analgesic effects of meperidine that decreased the perception of pain from dental procedures and increased the sedative impact of the regimen.
In the Pediatric Sedation Clinic, or PSC, in the School of Dentistry at the University of North Carolina at Chapel Hill, ChMH has been used as one of several regimens for more than a decade. Supplemental 100 percent oxygen, or O2, is added to ChMH based on the theoretical concept that 100 percent O2 elevates the partial pressure of arterial oxygen, or PaO2, in the sedated child, and this elevated PaO2 provides an extra measure of safety during conscious sedation.12
To date, there have been no reports or studies of adverse events using the ChMH/O2 sedative regimen. Therefore, the purpose of this article is to report adverse events and sedation outcomes from five years of experience using the ChMH/O2 regimen of chloral hydrate (50 mg/kg), meperidine (1.5 mg/kg) and hydroxyzine pamoate (25 mg) with 100 percent O2 supplementation.
We reviewed patients’ dental and anesthesia records during the five years from July 1, 1992, through June 30, 1997. All sedations were performed in healthy children referred to PSC because of their inability to cooperate for needed dental care in the conventional dental setting. Before sedation, the children’s pediatricians or family physicians evaluated them to ensure that they had no contraindications for outpatient conscious sedation.
A variety of sedative regimens with and without inhalation agents were employed in the PSC. In this study, we are reporting only on those children who received ChMH/O2 in all of their sedation visits. Our study focuses on ChMH/O2 because of its popularity among general and pediatric dentists and because there has been no report of adverse effects with this regimen. Our data are limited to children 24 to 84 months of age because our case files contain few ChMH/O2 cases for children younger than 24 months of age or older than 84 months of age.
Conscious sedation procedures. The PSC standard for conscious sedation protocol was followed for all cases included in this study. This protocol required dietary restrictions that permitted no milk or solid food up to eight hours and no clear liquid for up to four hours before oral drug administration in accordance with the AAPD’s Guidelines for the Elective Use of Pharmacologic Conscious Sedation and Deep Sedation in Pediatric Dental Patients.22,23 On the day of sedation, the child was weighed, and the oral medications, or meds, were dispensed by weight in a small cup. The child was asked to drink the meds from the cup. If the child refused, the meds were administered by syringe with a parent’s assistance. The method of administration and approximation of lost meds (in milliliters) were documented in the patient’s record. After drug administration, the child waited in a quiet, dimly lit holding area. Parents were urged to cuddle the children and rock them in a rocking chair to encourage a quiet waiting time.
We defined and recorded waiting time as the interval between drug administration and the seating of the child in the dental chair. Based on the sedative and analgesic agents in the ChMH, the recommended waiting time is 45 minutes. If the child was not drowsy or sleeping after 45 minutes, the operator had the prerogative to wait longer.
The parent or the operator carried the child to the operatory, and all children were secured on an immobilizing board to control involuntary movements that might occur during the dental procedure. Monitoring probes were attached. A nasal cannula was placed, and supplemental 100 percent O2 was administered continuously throughout the operation. The maximum dose of local anesthetic was limited strictly to 4.4 mg/kg for all patients.
Patients were monitored continuously using a pulse oximeter, a precordial stethoscope and visual observation. Capnography was adopted for routine use in the PSC in 1995; accordingly, end-tidal carbon dioxide, or ETCO2, measures were recorded in the anesthesia record from that time forward. A resident or attending faculty member was appointed as a dedicated monitoring assistant for each sedation. The monitoring assistant communicated as needed to help the operator with airway positioning and to leave the primary provider/dental operator (also a resident or attending faculty member) free to concentrate on the dental procedures. The monitoring assistant used a written time-based anesthesia record to document physiological signs every five minutes. Pulse rate; respiratory rate, or RR; oxyhemoglobin saturation, or SpO2; and ETCO2 (starting in 1995) were recorded. The monitoring assistant also documented the details and timing of any unusual or adverse events that occurred during the procedure. The dental operator documented the treatment rendered at each visit and the sedation outcome.
As a part of the protocol, each parent was given written postoperative instructions that included a telephone number at which to call the primary provider to report and discuss any postoperative sequelae or concerns. All such concerns were recorded in the patients’ records.
Data collection. Based on a comprehensive review of all sedation cases performed during the five-year period, 111 children met the inclusion criteria, which resulted in 195 conscious sedation appointments. All of the children were 24 to 84 months of age and received only ChMH/O2 for all sedation appointments. From these 111 children, we collected the following data from dental and anesthesia records: age, sex, weight, medical history, current medical conditions, total sedation visits, compliance in taking meds, waiting time, total milligrams of local anesthetic given, treatment duration, vital signs, SpO2, ETCO2 (starting in 1995), adverse events, treatment rendered, sedation outcomes and postoperative sequelae.
We defined true desaturation as a pulse oximeter reading of SpO2 below 95 percent taken while the patient was quiet and still. We defined true apnea as no visual signs of breathing, no breath sounds audible via precordial stethoscope and a capnograph reading of zero for RR and ETCO2 for 25 seconds.10 We defined prolonged sedation as one in which the child needed more than 30 minutes after the conclusion of dental treatment to recover and meet the discharge criteria recommended in AAPD’s guidelines20; in brief, the child needed to be walking, talking and drinking to be dismissed.
We recorded a sedation outcome based on the operator’s judgment using a subjective classification, wherein satisfactory sedation was defined as completion of planned care without difficulty. Unsatisfactory sedation was defined as a completion of planned care with difficulty due to disruptive behavior or completion of less care than planned. Aborted sedation was defined as discontinuation of care resulting from disruptive behavior with concerns for patient or dental team safety.
We collected the completed treatment as relative based value units, or RBVU, wherein all types of dental work were converted to numeric scores to make valid comparisons of the treatment rendered across all sedation appointments. For example, the score of a one-surface amalgam restoration in a primary tooth was 1.0, the score of a two-surface amalgam was 1.5, and the score of a prefabricated stainless steel crown in a primary tooth was 4.0.
The relative based value system called Dental Relative Based Value Scale/Units29,30 was developed in 1985 through surveys that collected input from practitioners valuing each dental procedure based on its time and difficulty. The data were received from thousands of dentists from all specialties and were analyzed for validity and normal distribution. Standard deviations and means were used to develop the scale. The relative value has been used as a way to value dental procedures across disciplines and specialties and is considered to be a reliable measure. It is used widely by health insurance organizations and Medicaid agencies to determine the value of procedures for reimbursement.30
Data analyses. Descriptive statistics were employed to illustrate results in frequencies and percentages. Each sedation visit was analyzed independently. We used 2 tests to assess statistical differences in categorical data, while we used Student t test and analysis of variance, or ANOVA, for continuous data. We used Bonferroni inequality tests to determine the difference between group studies when 2 tests revealed significant difference and Scheffé tests if ANOVA showed statistical significance.
RESULTS The study patients’ demographics are given in Table 1. There was no difference in sex distribution. Eighty-seven percent of the children (97/111) cooperated in drinking all their meds from a cup during 174 visits. Although parental and operator coaxing were sometimes needed, for only 13 percent of the children (14/111) in 21 sedation visits was it necessary to administer meds via syringe. The patients received all meds via the syringe in 10 of 21 visits, while the remainder lost some meds because of their refusal to swallow; for example, they expectorated at least some of the meds.
The mean waiting time was 60 minutes. Once they were in the dental chair, all of the patients were monitored continuously using visual assessment, a precordial stethoscope and a pulse oximeter. A capnograph was used in 41 percent of visits (80/195). The overall mean treatment duration was 63.5 minutes (range 15–120 minutes). Treatment included alloy and resin restorations, pulp therapy, stainless steel crowns, extractions, space maintainers, sealants and preventive care. Data sorted by sedation outcome are illustrated in Table 2. The proportion of satisfactory, or S; unsatisfactory, or U; and aborted, or A, sedations were 72 percent, 23 percent and 5 percent, respectively. There were no significant differences by age (P = .232) or weight (P = .768) among the three sedation outcomes. Among boys, outcomes were 77 percent S, 21 percent U and 2 percent A; among girls, the outcomes were 68 percent S, 24 percent U and 8 percent A. While boys tended to have more favorable outcomes, this sex distribution was not statistically significant (P = .092). Among the patients who drank all their meds from a cup (174/195), 75 percent had satisfactory sedation appointments, while 25 percent had either unsatisfactory or aborted sedation appointments. Only 48 percent of the patients who refused to drink their meds had satisfactory appointments. Sedation outcomes were higher among those children who drank all meds from a cup, and this difference was statistically significant (P = .013).
The mean waiting time was statistically significantly different among S, U and A sedation outcome groups (61, 58 and 49 minutes, respectively, P = .012). Scheffé test revealed that the mean waiting time of the S group was significantly longer than that of the A group.
The mean treatment duration of S and U groups were 65 and 64 minutes, respectively, and this difference was not statistically significant. Likewise, the RBVU was 11 and 12 in groups S and U, respectively, a difference that was not statistically significant (P = .193). In summary, there were no significant differences in the duration of treatment and amount of treatment achieved between the U and S groups.
Adverse events were reported in six of the 195 visits, or 3 percent of the sedation appointments. Adverse events included postoperative vomiting, true desaturation, true apnea and prolonged sedation (Table 3). All of the patients who experienced adverse events had satisfactory sedation appointments.
DISCUSSION We conducted this retrospective study to report the overall sedative outcomes using the ChMH oral regimen and assess the incidence of adverse effects. Although all sedation visits were performed in the same clinic setting and under the same strict protocol, multiple operators and monitoring assistants were involved. The findings must be interpreted recognizing these design limitations. Compliance with drinking meds. The oral route of administration is the most popular choice by pediatric dentists,28,31 but few studies have investigated acceptance for oral meds in children. Haas and colleagues32 compared the acceptance of oral chloral hydrate with oral midazolam for children 3 to 10 years of age, finding no difference in acceptance when both meds were mixed with syrup and orange juice. The ChMH oral regimen is a well-tolerated mixture, and we found that 91 percent of the children drank all their meds from the cup at their first sedation visit and only four patients refused to do so at the second visit. This was not surprising, as most children are accustomed to drinking meds from a cup and the bitterness of chloral hydrate is masked by the sweet taste of hydroxyzine in the ChMH regimen.
Among the noncompliant children, nine girls refused to drink meds compared with five boys. Ten children refused to do so in their first sedation visits, though they had no previous experience with the taste of these meds. In general, our findings suggest that a child’s refusal to drink meds should signal a concern; we recorded a loss of 5 to 30 percent of the meds using a syringe, and the percentage of successful sedation was lower in this group.
Waiting time. The waiting time for a given oral regimen varies depending on pharmacodynamics of the drugs in the specific regimen. Drug onset is the time in which the effect of the drug can be detected. For sedatives, onset might induce sleep in a nonstressful situation. Because dental procedures usually consist of multiple stimulations that include mild to moderate painful stimuli, the waiting time should be calculated to coincide with onset of the drugs’ peak effect.
PSC’s protocol recommends a waiting time of approximately 45 minutes. Occasionally children will go through a paradoxical excitation stage, which can prolong waiting time significantly. When the child is not sleeping or drowsy, more waiting time usually is given. There are, however, many occasions when the child may fall asleep soon after administration of meds, and this presents a temptation to initiate treatment sooner than the 45 minutes’ waiting time. On the basis of our findings, a strong argument can be made for waiting a minimum of 45 minutes for the ChMH regimen to take effect, no matter how profoundly the child is sleeping before this critical time. In some situations, children will fall asleep soon after receiving ChMH meds because of the rapid onset of the meperidine and hydroxyzine; however, the peak effect of the ChMH regimen is most likely in the range of 60 to 90 minutes. Hasty and colleagues10 speculated that sedation outcome would be better if invasive stimuli, such as injection and rubber dam clamp placement, are timed to occur as nearly as possible to the time of peak effect of meperidine.
Our findings suggest that waiting time may be a critical variable for a successful sedation outcome. Accordingly, physicians should thoughtfully consider this factor and pay attention to the specific actions of their sedation drugs. Most reported sedation studies do not describe or manage the waiting time variable; we suggest that waiting time should be analyzed more carefully in future sedation studies.
Waiting a sufficient amount of time between anesthetic administration and treatment may be a critical variable for a successful sedation outcome.
Sedation outcomes. We acknowledge that our assessment of sedation outcomes was highly subjective. The standard of research methodology for assessment of child behavior in the dental setting should rely on video technology using valid and reliable behavior assessment scales.33 We made no attempt to achieve this standard, and, thus, our sedation outcome results must be viewed as global and subjective. Nevertheless, our findings are consistent with other studies that have used the ChMH regimen with the same dosages for healthy children 24 to 48 months of age.
Nathan and West24 used a dichotomous behavioral rating scale and reported successful sedation (defined as treatment achieved without restraint) for 60 percent of their cases in a ChMH study involving 135 children whose mean age was 34 months. They also found that the ChMH regimen was 45.6 percent more successful than the regimen that used chloral hydrate and hydroxyzine alone. Croswell and colleagues25 reported a 66 percent success rate in 44 patients (mean age 39 months). Our findings are in the same general range, with a 72 percent success rate reported for 195 sedations (mean age 47 months).
Most previous sedation studies for preschool children have not addressed sex differences per se. One exception is a study by Needleman and colleagues11 that reports 15.5 percent greater success for boys than for girls in a sample of 385 sedations in 336 patients (mean age 30 months). In our study, we found that boys were more complaint in taking meds. Although not statistically significant, we found a clear trend that male sedation outcomes were more successful. Boys also had fewer aborted sedation visits—only two aborted appointments compared with eight aborted appointments for girls. Future pediatric sedation studies should examine potential sex differences more closely.
We found no difference in age and weight among our group of patients with different sedation outcomes, a similar finding to that reported by Needleman and colleagues.11 Our sample size, however, was too small to draw valid conclusions about age and weight as predictors of sedation outcomes.
Treatment outcomes. RBVUs represent unit values reflecting the time and effort to complete various dental procedures. We found these unit values to be useful in converting various types of dental procedures to a common denominator for comparison purposes. Although the system has not been used often in clinical research, it has been used widely for management and cost analysis purposes.30
We found no significant differences in mean value of care delivered in the satisfactory vs. unsatisfactory groups; indeed, the results showed slightly more work completed for the unsatisfactory group. We point out again that our sedation outcome assessment was subjective and based not on the quantity of treatment completed, but on the difficulty of completing care in a given situation and the operator’s judgment. The most likely explanation for our finding is that operators made every effort possible to complete the care for those children who were the most challenging in an attempt to limit future sedation visits or avoid care under general anesthesia.
We found that 93 children had all their treatment completed while under conscious sedation. Of the remaining 18 patients, five whose sedations were aborted were referred to have the remaining treatment completed while under general anesthesia. For the other 13 patients, treatments were not completed during the study period because of failed appointments or family relocation.
Vomiting as an adverse event. Although nausea and vomiting are common adverse reactions for both chloral hydrate and meperidine,5,6 we found only one such incident among the 195 sedations in this study. Hasty and colleagues10 reported no vomiting with ChMH/O2 for the 20 sedations in their study. In contrast, Needleman and colleagues11 reported 8.1 percent vomiting intraoperatively using chloral hydrate/hydroxyzine/nitrous oxide/O2. Nausea and vomiting are not uncommon side effects of N2O/O2.7 While we attribute the low incidence of vomiting in this study to our rigid adherence to the preoperative patient dietary restrictions, the absence of N2O/O2 cannot be discounted.
Apnea as an adverse event. A well-controlled study by Rohlfing and colleagues12 reported that the risk of experiencing apnea during conscious sedation was 39 percent, and the risk was equal in patients who received supplementary 100 percent O2 and those who did not. The respiratory depressive effects of narcotics plus synergistic drug reactions with sedative agents can increase the respiratory depression effect of a drug regimen, a phenomenon exacerbated by local anesthetics.19,25,34 We found only one episode of true apnea in this study, but this number probably is artificially low because a capnograph was not used in the first one-half of the study. Almost certainly we would have diagnosed more apneic episodes if a capnograph had been used in all cases.
Desaturation as an adverse event. There is compelling evidence that oxygen desaturation events occur during conscious sedation of pediatric patients; however, most desaturations are artifacts.35 We defined true desaturation as a pulse oximeter reading of SpO2 below 95 percent while the patient is quiet and still. We found only one episode of true desaturation in this study.
The benefit of O2 supplementation during conscious sedation has been suggested in several studies.9,10,12,25,36 It is our routine practice to provide all children with supplementary 100 percent O2 intraoperatively via nasal cannula. This technique is convenient, easy and inexpensive. Furthermore, this approach is well-tolerated by children and does not compromise the operator’s access in any way. We did not see desaturation after the one apneic episode reported here.
Prolonged sedation/slow recovery. Concern about the recovery period and discharge criteria were emphasized in AAPD’s guidelines.20,22,23 The discharge protocol in our study was to dismiss children within 15 to 30 minutes after the conclusion of the dental procedures if cardiovascular and respiratory functions were within normal limits. We expected to see more slow recoveries because both meperidine and chloral hydrate have reasonably long half-lives and wear off gradually within several hours.5,6 However, we found only three instances of prolonged sedation/slow recovery among 195 sedations. Furthermore, we had no documented circumstances of postoperative sedation–related sequelae after the patients were dismissed to return home.
CONCLUSIONS We acknowledge that this study is retrospective in nature, and it involved multiple operators over a five-year period. The method of assessing patient cooperation was subjective. The study, however, involved a highly standardized sedation protocol, including a written record of anesthesia and close attention to detail in record-keeping and chart documentation. Under the conditions of this study:
– adverse events occurred in only 3 percent of the sedation appointments when a strict sedation protocol was adhered to;
– the ChMH/O2 regimen yielded a 72 percent success rate, while 23 percent of the cases were unsuccessful, and 5 percent were aborted;
– compliance with taking oral medications and waiting time after medication intake were important factors in predicting sedation success.
FOOTNOTES
Dr. Leelataweedwud is a lecturer, Department of Pediatric Dentistry, Mahidol University, Faculty of Dentistry, 6 Yothi St., Bangkok 10400, Thailand, e-mail "dtple@mahidol.ac.th". Address reprint requests to Dr. Leelataweedwud.
Dr. Vann is a Demeriit Distinguished professor and the graduate program director, Department of Pediatric Dentistry, The University of North Carolina at Chapel Hill.
This study was supported by Maternal and Child Health Training for Leadership in Pediatric Dentistry Education grant MCJ 379494.
The authors are grateful to Miss Chulalak Komoltri for her statistical consultation for this investigation.
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Sedation
Sedation can range from the use of nitrous oxide to calm a patient to general anesthetics used to put patients to sleep. Patients with dental phobia, low pain tolerance, major dental treatment, physical handicaps or strong gag reflexes may require sedation. Procedures like fillings, crowns, root canals, extractions, cosmetic procedures and periodontal treatments often require sedation.
Sedation is endorsed by the American Dental Association and is an effective way to make many patients comfortable during their dental visit. Before using a sedative or anesthetic, it is important to tell your dentist about any medications or medical treatments your child is receiving. Before administering any sedative or anesthetic, your dentist will talk to you about the process of sedation and pre- and post-sedation instructions.
"Laughing Gas"
Nitrous oxide, more commonly known as laughing gas, is often used as a conscious sedative during a dental visit. The gas is administered with a mixture of oxygen and has a calming effect that helps phobic or anxious patients relax during their dental treatment. Because it is a mild sedative, patients are still conscious and can talk to their dentist during their visit. After treatment, the nitrous is turned off and oxygen is administered for five to 10 minutes to help flush any remaining gas. The effects wear off almost immediately. Nitrous oxide rarely has side effects, although some patients may experience minor nausea and constipation. Your doctor will provide you with pre- and post-sedation instructions.
Below is an article from the Journal of American Dental Association on Oral Conscious Sedation
J Am Dent Assoc, Vol 132, No 11, 1531-1539. © 2001 American Dental Association
RESEARCH
JADA Continuing Education
Adverse events and outcomes of conscious sedation for pediatric patients
Study of an oral sedation regimen
PATTARAWADEE LEELATAWEEDWUD, D.D.S., M.S. and WILLIAM F. VANN JR., D.M.D., M.S., Ph.D.
Background. The authors report on adverse events and sedation outcomes for an oral sedation regimen of chloral hydrate, meperidine and hydroxyzine with 100 percent oxygen, or O2, supplementation.
Methods. In a five-year retrospective study, the authors examined 195 records of conscious sedation performed in 111 healthy children aged 24 to 48 months (mean, 47 months). The authors analyzed age, sex, weight, methods of drug delivery, waiting time after drug administration, treatment rendered, treatment time, adverse events, sedation outcomes and the number of visits needed to complete treatment using descriptive statistics, 2 tests, t test and analysis of variance.
Results. Adverse events—including vomiting, desaturation, prolonged sedation and an apneic event—occurred in 3 percent of all sedations and were minor. Seventy-two percent of sedations had satisfactory behavioral outcomes, 23 percent had unsatisfactory outcomes, and 5 percent of the cases were aborted because of disruptive behavior. Sex was not a significant factor for the success. Patient compliance with drinking medications (P = .013) and a longer waiting time after medication intake (P = .012) yielded better sedation outcomes.
Conclusions. Minimal minor adverse events occurred with this sedation regimen. The success rate was 72 percent. Compliance with taking oral medications and waiting time appeared to be important factors in predicting sedation success.
Clinical Implications. This oral sedation regimen offers reasonable outcomes with minimal adverse events under a strict protocol and use of O2 supplementation. The results also revealed associations that give guidance for case selection and outcome prediction.
For many years, conscious sedation has been a popular pharmacological approach in the management of young uncooperative children who need invasive dental and medical procedures. While conscious sedation is believed to be used widely by general dental practitioners, or GPs, the frequency of its use by them is not well-documented. The published literature, however, does contain several reports that document the frequency with which pediatric dentists use conscious sedation. Davis1 surveyed the members of College of Diplomates of the American Board of Pediatric Dentistry in 1988 and reported that more than 76 percent of respondents used conscious sedation in their practices. In 1989 and 1993, Houpt chronicled the results of two large national surveys on the use of sedative agents by members of the American Academy of Pediatric Dentistry, or AAPD, referred to as Project USAP I2 and Project USAP II.3 The 1,497 respondents in Project USAP II3 reported 33,208 drug administrations for sedation in a three-month period. In 1996, Wilson4 reported the results of a survey that reviewed responses from 1,758 AADP members. Forty percent reported using sedation as frequently as one to five times weekly, and 20 percent reported using sedation more frequently than five times weekly.
An oral sedation of chloral hydrate, meperidine and hydroxyzine pamoate offers reasonable outcomes with minimal adverse events under a strict protocol and use of supplementary oxygen. Practitioners are aware that conscious sedation procedures carry risks from the potential side effects of the medications. For example, nausea and vomiting are not uncommon with sedation agents such as chloral hydrate, meperidine and nitrous oxide.5–7 The most serious adverse outcome of pediatric conscious sedation is respiratory compromise and its related consequences.8–14 Respiratory compromise can lead to hypoxemia and predispose children to a range of deleterious conditions.14
Morbidity and mortality from pediatric conscious sedation have been reported periodically.15–18 Since the publication of Goodson and Moore’s19 1983 article on sedation misadventures, the safety of sedation regimens for children has received considerable scrutiny. In 1985, the emergence of the Guidelines for the Elective Use of Conscious Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients20 elevated the professional standards for the safe provision of sedation of children. Professional discourse on the standards and their subsequent revisions by American Academy of Pediatrics in 199221 and AAPD in 199322 and in 199623 has led to increasing attention on the safety of conscious sedation of children, especially in a dental setting. Even so, conscious sedation for children still appears to carry significant potential for adverse outcomes. Wilson4 noted that of the 1,758 pediatric dentists who responded to his 1996 survey, 30 percent had experienced compromised airways in patients sedated with sedatives and nitrous oxide/oxygen analgesia, and 5 percent noted that they had activated emergency medical services secondary to sedation procedures.
Many drug regimens and routes of administration have been investigated and reported for conscious sedation of children in the dental setting. One regimen that has been the subject of several studies10,12,24,25 is an oral elixir of chloral hydrate (50 milligrams per kilogram), meperidine (1.5 mg/kg) and hydroxyzine pamoate (25 mg). In this context, we will refer to this elixir as the ChMH regimen. Previous studies have reported success rates with this regimen ranging from 60 to 66 percent.24,25
The rationale for ChMH. The rationale for the ChMH regimen is based on its potential for anxiolytic, analgesic and antiemetic effects. Chloral hydrate is a psychotropic agent with anxiolytic, sedative and hypnotic properties.6,26 It has a wide margin of safety and has been studied extensively as a sedative drug for children. It is relatively easy to administer and is well-absorbed orally, requiring approximately 30 to 60 minutes to reach its peak effect.5 Chloral hydrate is the most common sedative agent used in conscious sedation for pediatric dental patients.2,3
Meperidine is a narcotic analgesic with effects similar to, but less potent than, morphine.6 Its therapeutic actions include sedation and analgesia. Meperidine can cause respiratory depression, which can be potentiated by anxiolytic agents such as chloral hydrate. Oral meperidine has a rapid onset of 10 to 15 minutes; however, it requires one to two hours to reach its peak effect.27
Hydroxyzine pamoate is an antihistamine and psychotropic agent that possesses antiemetic, anxiolytic, sedative and hypnotic properties. Oral hydroxyzine is absorbed rapidly with onset within 15 to 30 minutes.28 It has a wide margin of safety and is a popular drug in pediatric conscious sedation.2,3 Hydroxyzine commonly is used as a sole agent or in combination with chloral hydrate and meperidine.26,28 When used as a combination drug with other central nervous system depressants, hydroxyzine can potentiate the central nervous system depression effect.6,28 The antihistamine and antiemetic properties of hydroxyzine are used to overcome the histamine-releasing effect of meperidine, as well as the nausea and vomiting effects of both chloral hydrate and meperidine. The adverse effects of hydroxyzine are mild and transitory in nature.6
Nathan and West24 reported better sedation outcomes by adding meperidine to chloral hydrate and hydroxyzine than with the same regimen without meperidine. Hasty and colleagues10 corroborated this finding and reported that meperidine did not increase the risk of experiencing complications, including respiratory compromise. They attributed the more favorable outcomes to the analgesic effects of meperidine that decreased the perception of pain from dental procedures and increased the sedative impact of the regimen.
In the Pediatric Sedation Clinic, or PSC, in the School of Dentistry at the University of North Carolina at Chapel Hill, ChMH has been used as one of several regimens for more than a decade. Supplemental 100 percent oxygen, or O2, is added to ChMH based on the theoretical concept that 100 percent O2 elevates the partial pressure of arterial oxygen, or PaO2, in the sedated child, and this elevated PaO2 provides an extra measure of safety during conscious sedation.12
To date, there have been no reports or studies of adverse events using the ChMH/O2 sedative regimen. Therefore, the purpose of this article is to report adverse events and sedation outcomes from five years of experience using the ChMH/O2 regimen of chloral hydrate (50 mg/kg), meperidine (1.5 mg/kg) and hydroxyzine pamoate (25 mg) with 100 percent O2 supplementation.
We reviewed patients’ dental and anesthesia records during the five years from July 1, 1992, through June 30, 1997. All sedations were performed in healthy children referred to PSC because of their inability to cooperate for needed dental care in the conventional dental setting. Before sedation, the children’s pediatricians or family physicians evaluated them to ensure that they had no contraindications for outpatient conscious sedation.
A variety of sedative regimens with and without inhalation agents were employed in the PSC. In this study, we are reporting only on those children who received ChMH/O2 in all of their sedation visits. Our study focuses on ChMH/O2 because of its popularity among general and pediatric dentists and because there has been no report of adverse effects with this regimen. Our data are limited to children 24 to 84 months of age because our case files contain few ChMH/O2 cases for children younger than 24 months of age or older than 84 months of age.
Conscious sedation procedures. The PSC standard for conscious sedation protocol was followed for all cases included in this study. This protocol required dietary restrictions that permitted no milk or solid food up to eight hours and no clear liquid for up to four hours before oral drug administration in accordance with the AAPD’s Guidelines for the Elective Use of Pharmacologic Conscious Sedation and Deep Sedation in Pediatric Dental Patients.22,23 On the day of sedation, the child was weighed, and the oral medications, or meds, were dispensed by weight in a small cup. The child was asked to drink the meds from the cup. If the child refused, the meds were administered by syringe with a parent’s assistance. The method of administration and approximation of lost meds (in milliliters) were documented in the patient’s record. After drug administration, the child waited in a quiet, dimly lit holding area. Parents were urged to cuddle the children and rock them in a rocking chair to encourage a quiet waiting time.
We defined and recorded waiting time as the interval between drug administration and the seating of the child in the dental chair. Based on the sedative and analgesic agents in the ChMH, the recommended waiting time is 45 minutes. If the child was not drowsy or sleeping after 45 minutes, the operator had the prerogative to wait longer.
The parent or the operator carried the child to the operatory, and all children were secured on an immobilizing board to control involuntary movements that might occur during the dental procedure. Monitoring probes were attached. A nasal cannula was placed, and supplemental 100 percent O2 was administered continuously throughout the operation. The maximum dose of local anesthetic was limited strictly to 4.4 mg/kg for all patients.
Patients were monitored continuously using a pulse oximeter, a precordial stethoscope and visual observation. Capnography was adopted for routine use in the PSC in 1995; accordingly, end-tidal carbon dioxide, or ETCO2, measures were recorded in the anesthesia record from that time forward. A resident or attending faculty member was appointed as a dedicated monitoring assistant for each sedation. The monitoring assistant communicated as needed to help the operator with airway positioning and to leave the primary provider/dental operator (also a resident or attending faculty member) free to concentrate on the dental procedures. The monitoring assistant used a written time-based anesthesia record to document physiological signs every five minutes. Pulse rate; respiratory rate, or RR; oxyhemoglobin saturation, or SpO2; and ETCO2 (starting in 1995) were recorded. The monitoring assistant also documented the details and timing of any unusual or adverse events that occurred during the procedure. The dental operator documented the treatment rendered at each visit and the sedation outcome.
As a part of the protocol, each parent was given written postoperative instructions that included a telephone number at which to call the primary provider to report and discuss any postoperative sequelae or concerns. All such concerns were recorded in the patients’ records.
Data collection. Based on a comprehensive review of all sedation cases performed during the five-year period, 111 children met the inclusion criteria, which resulted in 195 conscious sedation appointments. All of the children were 24 to 84 months of age and received only ChMH/O2 for all sedation appointments. From these 111 children, we collected the following data from dental and anesthesia records: age, sex, weight, medical history, current medical conditions, total sedation visits, compliance in taking meds, waiting time, total milligrams of local anesthetic given, treatment duration, vital signs, SpO2, ETCO2 (starting in 1995), adverse events, treatment rendered, sedation outcomes and postoperative sequelae.
We defined true desaturation as a pulse oximeter reading of SpO2 below 95 percent taken while the patient was quiet and still. We defined true apnea as no visual signs of breathing, no breath sounds audible via precordial stethoscope and a capnograph reading of zero for RR and ETCO2 for 25 seconds.10 We defined prolonged sedation as one in which the child needed more than 30 minutes after the conclusion of dental treatment to recover and meet the discharge criteria recommended in AAPD’s guidelines20; in brief, the child needed to be walking, talking and drinking to be dismissed.
We recorded a sedation outcome based on the operator’s judgment using a subjective classification, wherein satisfactory sedation was defined as completion of planned care without difficulty. Unsatisfactory sedation was defined as a completion of planned care with difficulty due to disruptive behavior or completion of less care than planned. Aborted sedation was defined as discontinuation of care resulting from disruptive behavior with concerns for patient or dental team safety.
We collected the completed treatment as relative based value units, or RBVU, wherein all types of dental work were converted to numeric scores to make valid comparisons of the treatment rendered across all sedation appointments. For example, the score of a one-surface amalgam restoration in a primary tooth was 1.0, the score of a two-surface amalgam was 1.5, and the score of a prefabricated stainless steel crown in a primary tooth was 4.0.
The relative based value system called Dental Relative Based Value Scale/Units29,30 was developed in 1985 through surveys that collected input from practitioners valuing each dental procedure based on its time and difficulty. The data were received from thousands of dentists from all specialties and were analyzed for validity and normal distribution. Standard deviations and means were used to develop the scale. The relative value has been used as a way to value dental procedures across disciplines and specialties and is considered to be a reliable measure. It is used widely by health insurance organizations and Medicaid agencies to determine the value of procedures for reimbursement.30
Data analyses. Descriptive statistics were employed to illustrate results in frequencies and percentages. Each sedation visit was analyzed independently. We used 2 tests to assess statistical differences in categorical data, while we used Student t test and analysis of variance, or ANOVA, for continuous data. We used Bonferroni inequality tests to determine the difference between group studies when 2 tests revealed significant difference and Scheffé tests if ANOVA showed statistical significance.
RESULTS The study patients’ demographics are given in Table 1. There was no difference in sex distribution. Eighty-seven percent of the children (97/111) cooperated in drinking all their meds from a cup during 174 visits. Although parental and operator coaxing were sometimes needed, for only 13 percent of the children (14/111) in 21 sedation visits was it necessary to administer meds via syringe. The patients received all meds via the syringe in 10 of 21 visits, while the remainder lost some meds because of their refusal to swallow; for example, they expectorated at least some of the meds.
The mean waiting time was 60 minutes. Once they were in the dental chair, all of the patients were monitored continuously using visual assessment, a precordial stethoscope and a pulse oximeter. A capnograph was used in 41 percent of visits (80/195). The overall mean treatment duration was 63.5 minutes (range 15–120 minutes). Treatment included alloy and resin restorations, pulp therapy, stainless steel crowns, extractions, space maintainers, sealants and preventive care. Data sorted by sedation outcome are illustrated in Table 2. The proportion of satisfactory, or S; unsatisfactory, or U; and aborted, or A, sedations were 72 percent, 23 percent and 5 percent, respectively. There were no significant differences by age (P = .232) or weight (P = .768) among the three sedation outcomes. Among boys, outcomes were 77 percent S, 21 percent U and 2 percent A; among girls, the outcomes were 68 percent S, 24 percent U and 8 percent A. While boys tended to have more favorable outcomes, this sex distribution was not statistically significant (P = .092). Among the patients who drank all their meds from a cup (174/195), 75 percent had satisfactory sedation appointments, while 25 percent had either unsatisfactory or aborted sedation appointments. Only 48 percent of the patients who refused to drink their meds had satisfactory appointments. Sedation outcomes were higher among those children who drank all meds from a cup, and this difference was statistically significant (P = .013).
The mean waiting time was statistically significantly different among S, U and A sedation outcome groups (61, 58 and 49 minutes, respectively, P = .012). Scheffé test revealed that the mean waiting time of the S group was significantly longer than that of the A group.
The mean treatment duration of S and U groups were 65 and 64 minutes, respectively, and this difference was not statistically significant. Likewise, the RBVU was 11 and 12 in groups S and U, respectively, a difference that was not statistically significant (P = .193). In summary, there were no significant differences in the duration of treatment and amount of treatment achieved between the U and S groups.
Adverse events were reported in six of the 195 visits, or 3 percent of the sedation appointments. Adverse events included postoperative vomiting, true desaturation, true apnea and prolonged sedation (Table 3). All of the patients who experienced adverse events had satisfactory sedation appointments.
DISCUSSION We conducted this retrospective study to report the overall sedative outcomes using the ChMH oral regimen and assess the incidence of adverse effects. Although all sedation visits were performed in the same clinic setting and under the same strict protocol, multiple operators and monitoring assistants were involved. The findings must be interpreted recognizing these design limitations. Compliance with drinking meds. The oral route of administration is the most popular choice by pediatric dentists,28,31 but few studies have investigated acceptance for oral meds in children. Haas and colleagues32 compared the acceptance of oral chloral hydrate with oral midazolam for children 3 to 10 years of age, finding no difference in acceptance when both meds were mixed with syrup and orange juice. The ChMH oral regimen is a well-tolerated mixture, and we found that 91 percent of the children drank all their meds from the cup at their first sedation visit and only four patients refused to do so at the second visit. This was not surprising, as most children are accustomed to drinking meds from a cup and the bitterness of chloral hydrate is masked by the sweet taste of hydroxyzine in the ChMH regimen.
Among the noncompliant children, nine girls refused to drink meds compared with five boys. Ten children refused to do so in their first sedation visits, though they had no previous experience with the taste of these meds. In general, our findings suggest that a child’s refusal to drink meds should signal a concern; we recorded a loss of 5 to 30 percent of the meds using a syringe, and the percentage of successful sedation was lower in this group.
Waiting time. The waiting time for a given oral regimen varies depending on pharmacodynamics of the drugs in the specific regimen. Drug onset is the time in which the effect of the drug can be detected. For sedatives, onset might induce sleep in a nonstressful situation. Because dental procedures usually consist of multiple stimulations that include mild to moderate painful stimuli, the waiting time should be calculated to coincide with onset of the drugs’ peak effect.
PSC’s protocol recommends a waiting time of approximately 45 minutes. Occasionally children will go through a paradoxical excitation stage, which can prolong waiting time significantly. When the child is not sleeping or drowsy, more waiting time usually is given. There are, however, many occasions when the child may fall asleep soon after administration of meds, and this presents a temptation to initiate treatment sooner than the 45 minutes’ waiting time. On the basis of our findings, a strong argument can be made for waiting a minimum of 45 minutes for the ChMH regimen to take effect, no matter how profoundly the child is sleeping before this critical time. In some situations, children will fall asleep soon after receiving ChMH meds because of the rapid onset of the meperidine and hydroxyzine; however, the peak effect of the ChMH regimen is most likely in the range of 60 to 90 minutes. Hasty and colleagues10 speculated that sedation outcome would be better if invasive stimuli, such as injection and rubber dam clamp placement, are timed to occur as nearly as possible to the time of peak effect of meperidine.
Our findings suggest that waiting time may be a critical variable for a successful sedation outcome. Accordingly, physicians should thoughtfully consider this factor and pay attention to the specific actions of their sedation drugs. Most reported sedation studies do not describe or manage the waiting time variable; we suggest that waiting time should be analyzed more carefully in future sedation studies.
Waiting a sufficient amount of time between anesthetic administration and treatment may be a critical variable for a successful sedation outcome.
Sedation outcomes. We acknowledge that our assessment of sedation outcomes was highly subjective. The standard of research methodology for assessment of child behavior in the dental setting should rely on video technology using valid and reliable behavior assessment scales.33 We made no attempt to achieve this standard, and, thus, our sedation outcome results must be viewed as global and subjective. Nevertheless, our findings are consistent with other studies that have used the ChMH regimen with the same dosages for healthy children 24 to 48 months of age.
Nathan and West24 used a dichotomous behavioral rating scale and reported successful sedation (defined as treatment achieved without restraint) for 60 percent of their cases in a ChMH study involving 135 children whose mean age was 34 months. They also found that the ChMH regimen was 45.6 percent more successful than the regimen that used chloral hydrate and hydroxyzine alone. Croswell and colleagues25 reported a 66 percent success rate in 44 patients (mean age 39 months). Our findings are in the same general range, with a 72 percent success rate reported for 195 sedations (mean age 47 months).
Most previous sedation studies for preschool children have not addressed sex differences per se. One exception is a study by Needleman and colleagues11 that reports 15.5 percent greater success for boys than for girls in a sample of 385 sedations in 336 patients (mean age 30 months). In our study, we found that boys were more complaint in taking meds. Although not statistically significant, we found a clear trend that male sedation outcomes were more successful. Boys also had fewer aborted sedation visits—only two aborted appointments compared with eight aborted appointments for girls. Future pediatric sedation studies should examine potential sex differences more closely.
We found no difference in age and weight among our group of patients with different sedation outcomes, a similar finding to that reported by Needleman and colleagues.11 Our sample size, however, was too small to draw valid conclusions about age and weight as predictors of sedation outcomes.
Treatment outcomes. RBVUs represent unit values reflecting the time and effort to complete various dental procedures. We found these unit values to be useful in converting various types of dental procedures to a common denominator for comparison purposes. Although the system has not been used often in clinical research, it has been used widely for management and cost analysis purposes.30
We found no significant differences in mean value of care delivered in the satisfactory vs. unsatisfactory groups; indeed, the results showed slightly more work completed for the unsatisfactory group. We point out again that our sedation outcome assessment was subjective and based not on the quantity of treatment completed, but on the difficulty of completing care in a given situation and the operator’s judgment. The most likely explanation for our finding is that operators made every effort possible to complete the care for those children who were the most challenging in an attempt to limit future sedation visits or avoid care under general anesthesia.
We found that 93 children had all their treatment completed while under conscious sedation. Of the remaining 18 patients, five whose sedations were aborted were referred to have the remaining treatment completed while under general anesthesia. For the other 13 patients, treatments were not completed during the study period because of failed appointments or family relocation.
Vomiting as an adverse event. Although nausea and vomiting are common adverse reactions for both chloral hydrate and meperidine,5,6 we found only one such incident among the 195 sedations in this study. Hasty and colleagues10 reported no vomiting with ChMH/O2 for the 20 sedations in their study. In contrast, Needleman and colleagues11 reported 8.1 percent vomiting intraoperatively using chloral hydrate/hydroxyzine/nitrous oxide/O2. Nausea and vomiting are not uncommon side effects of N2O/O2.7 While we attribute the low incidence of vomiting in this study to our rigid adherence to the preoperative patient dietary restrictions, the absence of N2O/O2 cannot be discounted.
Apnea as an adverse event. A well-controlled study by Rohlfing and colleagues12 reported that the risk of experiencing apnea during conscious sedation was 39 percent, and the risk was equal in patients who received supplementary 100 percent O2 and those who did not. The respiratory depressive effects of narcotics plus synergistic drug reactions with sedative agents can increase the respiratory depression effect of a drug regimen, a phenomenon exacerbated by local anesthetics.19,25,34 We found only one episode of true apnea in this study, but this number probably is artificially low because a capnograph was not used in the first one-half of the study. Almost certainly we would have diagnosed more apneic episodes if a capnograph had been used in all cases.
Desaturation as an adverse event. There is compelling evidence that oxygen desaturation events occur during conscious sedation of pediatric patients; however, most desaturations are artifacts.35 We defined true desaturation as a pulse oximeter reading of SpO2 below 95 percent while the patient is quiet and still. We found only one episode of true desaturation in this study.
The benefit of O2 supplementation during conscious sedation has been suggested in several studies.9,10,12,25,36 It is our routine practice to provide all children with supplementary 100 percent O2 intraoperatively via nasal cannula. This technique is convenient, easy and inexpensive. Furthermore, this approach is well-tolerated by children and does not compromise the operator’s access in any way. We did not see desaturation after the one apneic episode reported here.
Prolonged sedation/slow recovery. Concern about the recovery period and discharge criteria were emphasized in AAPD’s guidelines.20,22,23 The discharge protocol in our study was to dismiss children within 15 to 30 minutes after the conclusion of the dental procedures if cardiovascular and respiratory functions were within normal limits. We expected to see more slow recoveries because both meperidine and chloral hydrate have reasonably long half-lives and wear off gradually within several hours.5,6 However, we found only three instances of prolonged sedation/slow recovery among 195 sedations. Furthermore, we had no documented circumstances of postoperative sedation–related sequelae after the patients were dismissed to return home.
CONCLUSIONS We acknowledge that this study is retrospective in nature, and it involved multiple operators over a five-year period. The method of assessing patient cooperation was subjective. The study, however, involved a highly standardized sedation protocol, including a written record of anesthesia and close attention to detail in record-keeping and chart documentation. Under the conditions of this study:
– adverse events occurred in only 3 percent of the sedation appointments when a strict sedation protocol was adhered to;
– the ChMH/O2 regimen yielded a 72 percent success rate, while 23 percent of the cases were unsuccessful, and 5 percent were aborted;
– compliance with taking oral medications and waiting time after medication intake were important factors in predicting sedation success.
FOOTNOTES
Dr. Leelataweedwud is a lecturer, Department of Pediatric Dentistry, Mahidol University, Faculty of Dentistry, 6 Yothi St., Bangkok 10400, Thailand, e-mail "dtple@mahidol.ac.th". Address reprint requests to Dr. Leelataweedwud.
Dr. Vann is a Demeriit Distinguished professor and the graduate program director, Department of Pediatric Dentistry, The University of North Carolina at Chapel Hill.
This study was supported by Maternal and Child Health Training for Leadership in Pediatric Dentistry Education grant MCJ 379494.
The authors are grateful to Miss Chulalak Komoltri for her statistical consultation for this investigation.
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Hasty MF, Vann WF Jr., Dilley DC, Anderson JA. Conscious sedation of pediatric dental patients: an investigation of chloral hydrate, hydroxyzine pamoate, and meperidine vs. chloral hydrate and hydroxyzine pamoate. Pediatr Dent 1991;13:10–9.[Medline]
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Rohlfing GK, Dilley DC, Lucas WJ, Vann WF Jr. The effect of supplemental oxygen on apnea and oxygen saturation during pediatric conscious sedation. Pediatr Dent 1998;20:8–16.[Medline]
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Roelofse JA, Roelofse PG. Oxygen desaturation in a child receiving a combination of ketamine and midazolam for dental extractions. Anesth Prog 1997;44:68–70.[Medline]
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Early Treatment
Our practice can provide a wide range of dental services for your children. Our flexibility in our services saves you time and keeps your total dental care within one practice. Our emphasis is on total preventive care for our patients. Total care begins with regular hygiene visits, regular checkups and continued home oral health routines. We provide many preventative measures to keep your child’s teeth clean and healthy, including sealants and fluoride treatments. We also educate the parents in early detection of some common problems children may face, including thumb sucking, bruxism and baby bottle tooth decay. Our primary goal for your children’s dental development is to achieve and maintain optimum oral health through advances in techniques, technologies and by maintaining their scheduled dental exams.
Teething
Normally the first tooth erupts between ages 6 to 12 months. Gums are sore, tender and sometimes irritable until the age of 3. Rubbing sore gums gently with a clean finger, the back of a cold spoon or a cold, wet cloth helps soothe the gums. Teething rings work well, but avoid teething biscuits—they contain sugar that is not good for baby teeth.
While your baby is teething, it is important to monitor the teeth for signs of baby bottle decay. Examine the teeth, especially on the inside or the tongue side, every two weeks for dull spots (whiter than the tooth surface) or lines. A bottle containing anything other than water and left in an infant’s mouth while sleeping can cause decay. This happens because sugar in the liquid mixes with bacteria in dental plaque, forming acids that attack the tooth enamel. Each time a child drinks liquids containing sugar, acids attack the teeth for about 20 minutes. When awake, saliva carries away the liquid. During sleep, the saliva flow significantly decreases and liquids pool around the child’s teeth for long periods, covering the teeth in acids.
Infant’s New Teeth
The primary, or “baby,” teeth play a crucial role in dental development. Without them, a child cannot chew food properly and has difficulty speaking clearly. Primary teeth are vital to development of the jaws and for guiding the permanent (secondary) teeth into place when they replace the primary teeth around age 6.
Since primary teeth guide the permanent teeth into place, infants with missing primary teeth or infants who prematurely lose primary teeth may require a space maintainer, a device used to hold the natural space open. Without a maintainer, the teeth can tilt toward the empty space and cause permanent teeth to come in crooked. Missing teeth should always be mentioned to your family dentist. The way your child cares for his/her primary teeth plays a critical role in how he/she treats the permanent teeth. Children and adults are equally susceptible to plaque and gum problems—hence, the need for regular care and dental checkups.
A Child’s First Dental Visit
A child’s first dental visit should be scheduled around his/her first birthday. The most important part of the visit is getting to know and becoming comfortable with a doctor and his staff. A pleasant, comfortable first visit builds trust and helps put the child at ease during future dental visits. If possible, allow the child to sit in a parent’s lap in the exam room. Children should be encouraged to discuss any fears or anxiety they feel.
Why Primary Teeth Are Important
Primary teeth are important for several reasons. Foremost, good teeth allow a child to eat and maintain good nutrition. Healthy teeth allow for clear pronunciation and speech habits. The self-image that healthy teeth give a child is immeasurable. Primary teeth also guide eruption of the permanent teeth.
Good Diet and Healthy Teeth
The teeth, bones and soft tissue of the mouth require a healthy, well-balanced diet. A variety of foods from the five food groups helps minimize (and avoid) cavities and other dental problems. Most snacks that children eat cause cavities, so children should only receive healthy foods like vegetables, low-fat yogurt and cheeses, which promote strong teeth.
Infant Tooth Eruption
A child’s teeth actually start forming before birth. As early as 4 months of age, the primary or “baby” teeth push through the gums—the lower central incisors are first, then the upper central incisors. The remainder of the 20 primary teeth typically erupt by age 3, but the place and order varies.
Permanent teeth begin eruption around age 6, starting with the first molars and lower central incisors. This process continues until around age 21. Adults have 28 secondary (permanent) teeth—32 including the third molars (wisdom teeth).
Preventing Baby Bottle Tooth Decay
Tooth decay in infants can be minimized or totally prevented by not allowing sleeping infants to breast or bottle-feed. Infants that need a bottle to comfortably fall asleep should be given a water-filled bottle or a pacifier. Our office is dedicated to fighting baby bottle tooth decay. Let us know if you notice any signs of decay or anything unusual in your child’s mouth.
Teething
Normally the first tooth erupts between ages 6 to 12 months. Gums are sore, tender and sometimes irritable until the age of 3. Rubbing sore gums gently with a clean finger, the back of a cold spoon or a cold, wet cloth helps soothe the gums. Teething rings work well, but avoid teething biscuits—they contain sugar that is not good for baby teeth.
While your baby is teething, it is important to monitor the teeth for signs of baby bottle decay. Examine the teeth, especially on the inside or the tongue side, every two weeks for dull spots (whiter than the tooth surface) or lines. A bottle containing anything other than water and left in an infant’s mouth while sleeping can cause decay. This happens because sugar in the liquid mixes with bacteria in dental plaque, forming acids that attack the tooth enamel. Each time a child drinks liquids containing sugar, acids attack the teeth for about 20 minutes. When awake, saliva carries away the liquid. During sleep, the saliva flow significantly decreases and liquids pool around the child’s teeth for long periods, covering the teeth in acids.
Infant’s New Teeth
The primary, or “baby,” teeth play a crucial role in dental development. Without them, a child cannot chew food properly and has difficulty speaking clearly. Primary teeth are vital to development of the jaws and for guiding the permanent (secondary) teeth into place when they replace the primary teeth around age 6.
Since primary teeth guide the permanent teeth into place, infants with missing primary teeth or infants who prematurely lose primary teeth may require a space maintainer, a device used to hold the natural space open. Without a maintainer, the teeth can tilt toward the empty space and cause permanent teeth to come in crooked. Missing teeth should always be mentioned to your family dentist. The way your child cares for his/her primary teeth plays a critical role in how he/she treats the permanent teeth. Children and adults are equally susceptible to plaque and gum problems—hence, the need for regular care and dental checkups.
A Child’s First Dental Visit
A child’s first dental visit should be scheduled around his/her first birthday. The most important part of the visit is getting to know and becoming comfortable with a doctor and his staff. A pleasant, comfortable first visit builds trust and helps put the child at ease during future dental visits. If possible, allow the child to sit in a parent’s lap in the exam room. Children should be encouraged to discuss any fears or anxiety they feel.
Why Primary Teeth Are Important
Primary teeth are important for several reasons. Foremost, good teeth allow a child to eat and maintain good nutrition. Healthy teeth allow for clear pronunciation and speech habits. The self-image that healthy teeth give a child is immeasurable. Primary teeth also guide eruption of the permanent teeth.
Good Diet and Healthy Teeth
The teeth, bones and soft tissue of the mouth require a healthy, well-balanced diet. A variety of foods from the five food groups helps minimize (and avoid) cavities and other dental problems. Most snacks that children eat cause cavities, so children should only receive healthy foods like vegetables, low-fat yogurt and cheeses, which promote strong teeth.
Infant Tooth Eruption
A child’s teeth actually start forming before birth. As early as 4 months of age, the primary or “baby” teeth push through the gums—the lower central incisors are first, then the upper central incisors. The remainder of the 20 primary teeth typically erupt by age 3, but the place and order varies.
Permanent teeth begin eruption around age 6, starting with the first molars and lower central incisors. This process continues until around age 21. Adults have 28 secondary (permanent) teeth—32 including the third molars (wisdom teeth).
Preventing Baby Bottle Tooth Decay
Tooth decay in infants can be minimized or totally prevented by not allowing sleeping infants to breast or bottle-feed. Infants that need a bottle to comfortably fall asleep should be given a water-filled bottle or a pacifier. Our office is dedicated to fighting baby bottle tooth decay. Let us know if you notice any signs of decay or anything unusual in your child’s mouth.
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