F O U RT H E D I T I O N

THE Handbook OF PEDIATRIC DENTISTRY

The American Academy of Pediatric Dentistry

THE Handbook
O F P E D I AT R I C D E N T I S T RY
FOURTH EDITION
Arthur J Nowak

E D I T E D B Y

&
& Paul S Casamassimo

Arthur J Nowak
Paul S Casamassimo
 F O U RT H E D I T I O N
T h e A m e r i c a n A c a d e m y o f P e d i a t r i c D e n t i s t r y

THE Handbook
O F P E D I AT R I C DENTISTRY

E D I T E D B Y

Arthur J Nowak
& Paul S Casamassimo

Copyright American Academy of Pediatric Dentistry 2011

ISBN 978-0-9670344-4-7
 Introduction to the Handbook,
Fourth Edition

The fourth edition of the Handbook of Pediatric Dentistry features additional changes to make
it more user friendly and provide users with additional resources beyond the pages of this
book:

more relevant to a ready-reference text such as a handbook

additional information that is often needed in the clinical practice of pediatric

dentistry

chapter’s table of contents

devices – please see the back inside cover of this book for mobile application login

The editors would like to thank the current chapter authors for their contributions to this
edition of the Handbook. We are also extremely grateful to those previous chapter authors
who contributed to the original editions of the book and set the foundation for this current
edition. The Handbook has been successful beyond our expectations and we thank those
scientist and clinician colleagues who made the Handbook one of the most used tools in our
specialty.

any text of this type is already dated upon publication due to the lag between completion

recommendations for improvement such as useful websites and new Academy policies and
guidelines.

Arthur J Nowak, DMD, MA

Paul S Casamassimo, DDS, MS
 Co-Editors
Arthur J Nowak, DMD, MA Paul S Casamassimo, DDS, MS
Departments of Pediatric Dentistry and Division of Pediatric Dentistry
Pediatrics (Emeritus) College of Dentistry
University of Iowa The Ohio State University and
Iowa City, Iowa Columbus Children’s Hospital
Columbus, Ohio

Chapter Authors
Steven M Adair, DDS Terence Chan, DDS, MSD
Church Street Health Management University of Detroit Mercy School of Dentistry
Nashville, Tennessee Detroit, Michigan
Homa Amini, DDS, MPH, MS Karen M Crews, DMD
The Ohio State University and Department of Pediatric and Public Health
Columbus Children’s Hospital Dentistry
Columbus, Ohio School of Dentistry
University of Mississippi
Ronald A Bell, DDS, MEd
Jackson, Mississippi
Medical University of South Carolina
Charleston, South Carolina Marcio A DaFonseca, DDS, MS
Department of Pediatric Dentistry
Joel H Berg, DDS, MS
University of Washington School of Dentistry
Department of Pediatric Dentistry
Seattle, Washington
University of Washington School of Dentistry
Seattle, Washington Jeffrey A Dean, DDS, MSD
Indiana University and
Robert J Berkowitz, DDS
The James Whitcomb Riley Hospital for
University of Rochester and
Children
Golisano Children’s Hospital at Strong
Indianapolis, Indiana
Rochester, New York
Kevin J Donly, DDS, MS
Kevin L Boyd, MS, DDS
Department of Developmental Dentistry
Private Practice of Dentistry for Children and
The University of Texas Health Science Center
Families
at San Antonio
Chicago, Illinois
San Antonio, Texas
Tegwyn H Brickhouse, DDS, PhD
Neva Penton Eklund, DMD
Department of Pediatric Dentistry
Department of Pediatric and Public Health
Virginia Commonwealth University
Dentistry
Richmond, Virginia
School of Dentistry
Richard M Burke, Jr, DMD University of Mississippi
Department of Pediatric Dentistry Jackson, Mississippi
College of Dentistry
Catherine M Flaitz, DDS
University of Iowa
University of Texas School of Dentistry
Iowa City, Iowa
Houston, Texas
Michael J Casas, DDS, MSc, FRCD(C)
University of Toronto and
The Hospital for Sick Children
Toronto, Ontario
CANADA
Anna B Fuks, DDS Purnima S Kumar, MDS, PhD
Department of Pediatric Dentistry Division of Periodontology
Hadassah School of Dental Medicine College of Dentistry
Hebrew University The Ohio State University
Jerusalem Columbus, Ohio
ISRAEL
Rochelle G Lindemeyer, DMD
Steven Ganzberg, DMD, MS School of Dental Medicine
Section of Anesthesiology University of Pennsylvania and
School of Dentistry Children’s Hospital of Philadelphia
University of California, Los Angeles Philadelphia, Pennsylvania
Los Angeles, California
Jessica Y Lee, DDS, MPH, PhD
Ann Griffen, DDS, MS Departments of Pediatric Dentistry and
Division of Pediatric Dentistry Health Policy and Management
College of Dentistry University of North Carolina
The Ohio State University Chapel Hill, North Carolina
Columbus, Ohio
Dennis J McTigue, DDS,MS
Jeffrey M Karp, DMD MS Division of Pediatric Dentistry and Community
University of Rochester and Oral Health
Golisano Children’s Hospital at Strong College of Dentistry
Rochester, New York The Ohio State University
Columbus, Ohio
Lewis A Kay AB, DDS
Temple University/Episcopal Division Gail Molinari, DDS, MS
Philadelphia, Pennsylvania Private Practice
Martha Ann Keels, DDS PhD
Division of Pediatric Dentistry Amr M Moursi, DDS, PhD
Duke Children’s Hospital Department of Pediatric Dentistry
Durham, North Carolina New York University College of Dentistry
and Bellevue Hospital Center
Michael Kanellis, DDS, MS
New York, New York
Department of Pediatric Dentistry
College of Dentistry Howard L Needleman, DMD
University of Iowa Children’s Hospital Boston and
Iowa City, Iowa Harvard School of Dental Medicine
Boston, Massachusetts
Constance M Killian, DMD
Children’s Hospital of Philadelphia and Charles Post, DDS
Private Practice of Pediatric Dentistry Children’s Hospital of Wisconsin
Doylestown, Pennsylvania Milwaukee, Wisconsin
Paul E Kittle, DDS Brian J Sanders, DDS, MS
Private Practice Pediatric Dentistry Indiana University and
Leavenworth, Kansas The James Whitcomb Riley Hospital for
Children
Ashok Kumar DDS, MS
Indianapolis, Indiana
College of Dentistry
The Ohio State University and Georgiana M Sanders, MD, MS
Columbus Children‘s Hospital Division of Allergy and Immunology
Columbus, Ohio Departments of Internal Medicine and Pediatrics
University of Michigan Medical School
Ann Arbor, Michigan
JC Shirley, DMD, MS Amy L Truesdale, DDS
Pediatric Dentistry College of Dentistry
Center for Craniofacial Disorders New York University
Children’s Healthcare of Atlanta New York, New York
Atlanta, Georgia
Erwin G Turner, DMD
Barbara Sheller, DDS, MSD Cincinnati Children’s Hospital Medical Center
Department of Dentistry Cincinnati, Ohio
Seattle Children’s Hospital
Kaaren G Vargas, DDS, PhD
Seattle, Washington
Private Practice
Rebecca L Slayton, DDS, PhD Corridor Kids Pediatric Dentistry
Department of Pediatric Dentistry North Liberty, Iowa
College of Dentistry
Paul O Walker, DDS, MS
University of Iowa
Indiana University Dental School and
Iowa City, Iowa
Riley Children’s Hospital
Megann Smiley, DMD, MS Indianapolis, Indiana
Departments of Dentistry and Anesthesiology,
John J Warren, DDS, MS
Nationwide Children’s Hospital
College of Dentistry
Columbus, Ohio
The University of Iowa
Jenny Ison Stigers, DMD Iowa City, Iowa
College of Dentistry
Karin Weber-Gasparoni, DDS, MS,
University of Kentucky
PhD
Lexington, Kentucky
Department of Pediatric Dentistry
Sarat Thikkurissy, DDS, MS College of Dentistry
Division of Pediatric Dentistry and Community University of Iowa
Oral Health Iowa City, Iowa
The Ohio State University College of Dentistry
Stephen Wilson, DMD, MA, PhD
Nationwide Children’s Hospital
Cincinnati Children’s Medical Center and
Ruwaida Tootla, PhD, MDentSci, University of Louisville
FRCDC Cincinnati, Ohio
Department of Orthodontics and Pediatric
Dentistry
University of Michigan
Ann Arbor, Michigan
 TABLE OF CONTENTS

CHAPTER 1: INFANT ORAL HEALTH

2 DEFINITION
2 RATIONALE
2 GOALS
2 STEPS INVOLVED IN INFANT ORAL HEALTH
3 ANTICIPATORY GUIDANCE (T)
4 ORAL HEALTH RISK ASSESSMENT (T)
6 CARIES RISK ASSESSMENT FORM FOR 0-5 YEAR OLDS (T)
7 CARIES MANAGEMENT PROTOCOL FOR 1-2 YEAR OLDS (T)
9 RESPONSIBILITY OF NON-DENTAL PROFESSIONALS
REGARDING INFANT ORAL HEALTH (T)
9 ADDITIONAL READINGS AND WEBSITES

CHAPTER 2: DENTAL DEVELOPMENT, MORPHOLOGY, ERUPTION

AND RELATED PATHOLOGIES
11 DENTAL DEVELOPMENTAL STAGES
12 DENTAL DEVELOPMENTAL ANOMALIES
21 ABNORMALITIES OF COLOR
22 ERUPTION OF TEETH
23 ANOMALIES OF ERUPTION
28 TABLES (T)
30 ADDITIONAL READINGS AND WEBSITES

Table of Contents vii

 CHAPTER 3: ORAL PATHOLOGY/ORAL MEDICINE/SYNDROMES
33 INFANT SOFT TISSUE LESIONS
34 WHITE LESIONS
36 LOCALIZED GINGIVAL LESIONS
37 GENERALIZED GINGIVAL ENLARGEMENTS
39 PIGMENTATION
40 HEMORRHAGE AND/OR HEMORRHAGIC LESIONS
41 LIP AND BUCCAL SWELLINGS
42 MACROGLOSSIA
44 SUBLINGUAL SWELLINGS
45 SOFT TISSUE NECK SWELLINGS
46 PALATAL SWELLINGS
47 MAXILLARY AND/OR MANDIBULAR
ENLARGEMENTS
49 ORAL ULCERS/STOMATITIS
51 MULTILOCULAR RADIOLUCENCIES
53 SOLITARY OR MULTIPLE RADIOLUCENCIES WITH
INDISTINCT OR RAGGED BORDERS
55 PERIAPICAL MIXED RADIOLUCENCIES-
RADIOPACITIES-DIFFERENTIAL DIAGNOSIS
56 PERICORONAL RADIOLUCENCIES
57 PERICORONAL RADIOLUCENCIES
CONTAINING RADIOPACITIES
58 RADIOLUCENCIES WITH DISTINCT BORDERS
59 CLEFT LIP AND PALATE
60 CRANIOSYNOSTOSIS
61 DWARFISM
62 ADDITIONAL READINGS AND WEBSITES

CHAPTER 4: FLUORIDE
66 MECHANISM OF ACTION
66 FLUORIDE DENTIFRICES
66 FLUORIDE RINSES
66 SELF-APPLIED GELS
67 FLUORIDE VARNISH
67 PROFESSIONALLY APPPLIED GELS AND FOAM

viii The Handbook of Pediatric Dentistry

 67 FLUORIDATED WATER
67 DIETARY FLUORIDE
68 FLUORIDE SUPPLEMENTS (T)
68 FLUOROSIS ISSUE
68 ACUTE FLUORIDE TOXICITY
69 FLUORIDE CONCENTRATION OF COMMERCIAL PRODUCTS (T)
69 FLUORIDE CONTENT OF INFANT FORMULAS (T)
69 FLUORIDE COMPOUND/ION CONCENTRATION
CONVERSIONS (T)
70 PRESCRIPTION EXAMPLES (T)
70 FLUORIDE PRODUCTS
72 ADDITIONAL READINGS AND WEBSITES

CHAPTER 5: RADIOLOGY
75 RADIOGRAPHIC PRINCIPLES
76 RADIATION HYGIENE
76 TECHNOLOGICAL ADVANCES
78 RISKS AND EFFECTS
78 TECHNIQUES/INDICATIONS
80 RECORDKEEPING/ADMINISTRATIVE MANAGEMENT
80 ADDITIONAL READING AND WEBSITES (T)

CHAPTER 6: PERIODONTAL DISEASES AND CONDITIONS

83 GINGIVAL DISEASE
85 CHRONIC PERIODONTITIS
85 AGGRESSIVE PERIODONTITIS
86 PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC
DISEASE
88 DEVELOPMENTAL OR ACQUIRED DEFORMITIES OR
CONDITIONS
89 CLINICAL PERIODONTAL EXAMINATION
89 ADDITIONAL READINGS AND WEBSITES

Table of Contents ix
 CHAPTER 7: PULP THERAPY IN PRIMARY AND YOUNG
PERMANENT TEETH
91 CLINICAL AND RADIOGRAPHIC ASSESSMENT OF
PULP STATUS (T)
92 VITAL PULP THERAPY FOR PRIMARY TEETH (T)
94 NON-VITAL PULP THERAPY FOR PRIMARY
TEETH (RX)
96 VITAL PULP THREATMENT IN YOUNG PERMANENT TEETH
97 NON-VITAL PULP THERAPY FOR YOUNG
PERMANENT TEETH
98 ADDITIONAL READINGS AND WEBSITES

CHAPTER 8: RESTORATIVE DENTISTRY

100 AMALGAM (T)
101 CAVITY LINERS
101 CAVITY VARNISHES
102 STAINLESS STEEL CROWNS (T)
102 RESIN-BASED COMPOSITES AND BONDING AGENTS
104 RESIN INFILTRATION
105 GLASS IONOMER CEMENTS
106 CAVITY PREPARATION IN PRIMARY TEETH
107 MANAGING OCCLUSAL SURFACES OF YOUNG PERMANENT
TEETH (T)
107 OCCLUSAL SEALANTS
108 ADDITIONAL READINGS AND WEBSITES

CHAPTER 9: TRAUMA
110 DIAGNOSTIC WORKUP
110 SAMPLE TRAUMA NOTE (T)
110 TRIAGE (T)
111 EXAMINATION (T)
112 RADIOGRAPHS
112 FUNDAMENTAL ISSUES
113 TREATMENT ALGORITHMS
116 COMPLICATIONS
116 SOFT TISSUE INJURIES
116 ORAL ELECTRICAL BURNS (T)
117 ADDITIONAL READINGS AND WEBSITES
x The Handbook of Pediatric Dentistry
CHAPTER 10: GROWTH AND DEVELOPMENT/MANAGEMENT OF
THE DEVELOPING OCCLUSION
120 BASICS OF CRANIOFACIAL GROWTH (T)
124 CLINICAL EVALUATION OF THE PRIMARY DENTITION
125 MANAGEMENT OF THE PRIMARY DENTITION
SPACE MAINTENANCE
POSTERIOR CROSSBITE
ANTERIOR CROSSBITE
NON-NUTRITIVE SUCKING HABITS (NNS)
AIRWAY COMPROMISE/MOUTHBREATHING

127 CLINICAL EVALUATION OF THE MIXED DENTITION

129 MANAGEMENT OF THE MIXED DENTITION
OVERVIEW OF SPACE SUPERVISION/GUIDANCE OF ERUPTION
SPACE MAINTENANCE
REGAINING LOST POSTERIOR SPACE
MANDIBULAR INCISOR CROWDING/ARCH LENGTH
DISCREPANCY
ECTOPIC ERUPTION OF FIRST PERMANENT MOLARS
DENTAL/FUNCTIONAL ANTERIOR CROSSBITE
ANTERIOR OPENBITE WITH EXTRAORAL HABIT
POSTERIOR CROSSBITE
MAXILLARY CANINE ERUPTIVE DISPLACEMENT
CONGENITALLY MISSING PERMANENT TEETH
ANKYLOSED TEETH
SUPERNUMERARY TEETH

138 TREATING SKELETAL MALOCCLUSIONS IN THE MIXED

DENTITION
OVERVIEW
TRANSVERSE BASAL ARCH EXPANSION
ANTEROPOSTERIOR CLASS II MALOCCLUSION > RETRUSIVE
MANDIBLE > FUNCTIONAL APPLIANCE
ANTEROPOSTERIOR CLASS II MALOCCLUSION >
PROTRUSIVE MANDIBLE > DIRECTED HEADGEAR
ANTEROPOSTERIOR CLASS II MALOCCLUSION WITH
ACCEPTABLE A-P SKELETAL/PROFILE RELATIONSHIPS
ANTEROPOSTERIOR CLASS III MALOCCLUSION

141 ADDITIONAL READINGS AND WEBSITES

CHAPTER 11: RECORDKEEPING AND FORMS

143 GENERAL INFORMATION AND PRINCIPLES
143 PATIENT INFORMATION SECTION
143 MEDICAL AND DENTAL HISTORY
144 EXAMINATION AND TREATMENT PLANNING
145 TRAUMA ASSESSMENT

Table of Contents xi
 145 PHARMACOLOGICAL/BEHAVIOR GUIDANCE
146 PREVENTIVE RECALL
146 RESTORATIVE
146 COMPREHENSIVE ORTHODONTIC
146 CONSULTATION REQUEST
147 INFORMED CONSENT
148 CONFIDENTIALITY AND HIPAA
148 ADDITIONAL READING AND WEBSITES

CHAPTER 12: INFECTION CONTROL

151 GUIDELINES FOR EXPOSURE DETERMINATION AND
PREVENTION
152 USE OF PERSONAL PROTECTIVE EQUIPMENT (T)
152 INFECTION CONTROL CATEGORIES OF PATIENT CARE
INSTRUMENTS (T)
153 METHOD FOR STERILIZING AND DISINFECTING PATIENT-
CARE ITEMS AND ENVIRONMENTAL SURFACES (T)
155 MAJOR METHODS OF STERILIZATION (T)
156 GUIDE FOR SELECTION OF APPROPRIATE DISINFECTION
METHODS FOR ITEMS TRANSPORTED TO OR FROM THE
DENTAL LABORATORY (T)
157 ADDITIONAL READINGS AND WEBSITES

CHAPTER 13: BEHAVIOR GUIDANCE

159 CLASSIC BEHAVIOR THEORIES
159 CONTEMPORARY BEHAVIOR THEORIES
159 BEHAVIOR GUIDANCE PRINCIPLES
160 BEHAVIOR GUIDANCE TECHNIQUES
160 SEDATION (T)
162 SEDATION ROUTES
163 MEDICATIONS
164 PRE-SEDATION PREPARATION
165 MONITORING PRINCIPLES
166 EMERGENCIES
167 ADDITIONAL READING AND WEBSITES

xii The Handbook of Pediatric Dentistry

CHAPTER 14: PAIN CONTROL
169 INDICATIONS
169 TECHNIQUES OF LOCAL ANESTHESIA
169 MAXIMUM RECOMMENDED DOSAGES (T)
170 LOCAL ANESTHETIC OVERDOSE
170 COMPLICATIONS OF LOCAL ANESTHESIA
171 ANALGESIA FOR CHILDREN
172 ADDITIONAL READINGS AND WEBSITES

CHAPTER 15: HOSPITAL DENTISTRY AND GENERAL

ANESTHESIA
174 HOSPITAL OPPORTUNITIES
174 REQUIREMENTS FOR MEDICAL STAFF MEMBERSHIP
AND HOSPITAL PRIVILEGES
174 GOALS OF GENERAL ANESTHESIA (T)
176 PRE-OPERATIVE WORKUP AND CONSULTATION (T)
177 PRE-ANESTHETIC PHYSICAL EXAMINATION
178 PRE-SURGERY DOCUMENTATION
179 PRE-SURGERY ANESTHESIA ASSESSMENT
179 OPERATING ROOM PROTOCOL
181 POST-SURGICAL ORDERS
182 OPERATIVE REPORT
182 DISCHARGE CRITERIA (T)
183 POST-OPERATIVE INSTRUCTIONS (RX)
184 POST-SURGICAL COMPLICATIONS
184 ADDITIONAL READINGS AND WEBSITES

CHAPTER 16: MEDICAL EMERGENCIES

186 PREPARATION FOR EMERGENCIES (T)
188 PREVENTION OF EMERGENCIES
188 MANAGEMENT OF EMERGENCIES-GENERAL PRINCIPLES
189 COMMON MEDICAL EMERGENCIES
194 SUMMARY (T)
196 ADDITIONAL READINGS AND WEBSITES

Table of Contents xiii

 CHAPTER 17: ALLERGIC AND IMMUNE DISORDERS
198 ANAPHYLAXIS
199 ALLERGIC RHINITIS
200 ATOPIC DERMATITIS
201 URTICARIA AND ANGIOEDEMA
202 HEREDITARY ANGIOEDEMA
203 FOOD ALLERGY
204 LATEX ALLERGY (T)
207 ASTHMA
212 RHEUMATOLOGIC DISEASES
JUVENILE ARTHRITIS
VASCULITIDES IN CHILDREN
SYSTEMIC LUPUS ERYTHEMATOSUS

217 CONGENITAL AND ACQUIRED IMMUNODEFICIENCIES (T)

224 ADDITIONAL READINGS AND WEBSITES

CHAPTER 18: CHILDHOOD CANCER

226 INCIDENCE AND OUTCOMES
227 ORAL COMPLICATIONS OF CHEMOTHERAPY
AND RADIOTHERAPY
228 ORAL AND DENTAL MANAGEMENT
231 ADDITIONAL READINGS AND WEBSITES

CHAPTER 19: CARDIOVASCULAR DISEASES

233 CONGENITAL HEART DISEASE
233 RHEUMATIC FEVER
234 RHEUMATIC HEART DISEASE
234 HEART MURMUR
235 CARDIAC ARRHYTHMIAS
236 HYPERTENSIVE HEART DISEASE
237 CONGESTIVE HEART FAILURE
238 INFECTIVE ENDOCARDITIS
238 CARDIAC CONDITIONS ASSOCIATED WITH INFECTIVE
ENDOCARDITIS
239 DENTAL PROCEDURES REQUIRING PROPHYLAXIS AND
INFECTIVE ENDOCARDITIS REGIMENS (T)
240 ADDITIONAL READINGS AND WEBSITES

xiv The Handbook of Pediatric Dentistry

CHAPTER 20: ENDOCRINE DISORDERS
242 PANCREAS
244 THYROID GLAND
247 ADRENAL GLAND
251 PARATHYROID GLAND
252 PITUITARY GLAND
255 ADDITIONAL READINGS AND WEBSITES

CHAPTER 21: HEMATOLOGIC DISORDERS

257 ANEMIAS
257 BLEEDING DISORDERS
258 ORAL EVALUATION
259 MANAGEMENT
259 ADDITIONAL READINGS AND WEBSITES

CHAPTER 22: INFECTIOUS DISEASES

261 PREVENTION (T)
261 BACTERIAL INFECTIONS
264 VIRAL INFECTIONS (T)
270 FUNGAL INFECTIONS
271 PARASITE INFECTIONS
271 ADDITIONAL READINGS AND WEBSITES

CHAPTER 23: NEPHROLOGY

274 DEFINITIONS
274 MEDICAL TREATMENT OF END STAGE RENAL DISEASE
(ESRD) (T)
275 PROPHYLACTIC ANTIBIOTICS PRIOR TO
DENTAL TREATMENT
276 ORAL AND DENTAL MANAGEMENT
279 ADDITIONAL READINGS AND WEBSITES

CHAPTER 24: PATIENTS WITH SPECIAL HEALTH CARE NEEDS

281 AUTISM AND AUTISM SPECTRUM DISORDER
283 ATTENTION DEFICIT HYPERACTIVITY DISORDER
285 INTELLECTUAL DISABILITY/DEVELOPMENTAL DELAY
286 SEIZURE DISORDER
288 MITACHONDRIAL DISORDERS

Table of Contents xv
 290 NEURAL TUBE DEFECTS
291 HYDROCEPHALUS
292 CEREBRAL PALSY
294 MUSCULAR DYSTROPHIES (MD)
294 DEAFNESS
295 ADDITIONAL READINGS AND WEBSITES

CHAPTER 25: NEW MORBIDITIES

298 PREGNANCY (T)
303 EATING DISORDERS
305 OVERWEIGHT AND OBESITY
308 CHILD ABUSE AND NEGLECT (T)
311 SUBSTANCE ABUSE
316 TOBACCO USE AMONG YOUTH (T)
321 ADDITIONAL READINGS AND WEBSITES

CHAPTER 26: RESOURCE SECTION

325 GROWTH CHARTS
329 BODY MASS INDEX (BMI) CHARTS
331 DIETARY GUIDELINES FOR AMERICA – 2010
333 RECOMMENDED FOOD INTAKE PATTERNS
335 SPEECH AND LANGUAGE MILESTONES
336 ASSESSMENT OF ACUTE TRAUMATIC INJURIES
338 PREPARING FOR YOUR CHILD’S SEDATION VISIT
340 SEDATION RECORD
342 POST-OPERATIVE INSTRUCTIONS FOR EXTRACTIONS/ORAL
SURGERY
344 COMMON LABORATORY VALUES
345 COMMON PEDIATRIC MEDICATIONS
347 MANAGEMENT OF MEDICAL EMERGENCIES

xvi The Handbook of Pediatric Dentistry

 Chapter 1: INFANT ORAL HEALTH

Karen Weber-Gasparoni and Jessica Y. Lee

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf
http://www.aapd.org/media/Policies_ Guidelines/G_ InfantOralHealthCare.pdf
http://www.aapd.org/media/Policies_Guidelines/P_CariesRiskAssess.pdf

2 DEFINITION
2 RATIONALE
2 GOALS
2 STEPS INVOLVED IN INFANT ORAL HEALTH
3 ANTICIPATORY GUIDANCE (T)
4 ORAL HEALTH RISK ASSESSMENT (T)
6 CARIES RISK ASSESSMENT FORM FOR 0-5 YEAR
OLDS (T)
7 CARIES MANAGEMENT PROTOCOL FOR 1-2 YEAR
OLDS (T)
9 RESPONSIBILITY OF NON-DENTAL
PROFESSIONALS REGARDING INFANT ORAL
HEALTH (T)
9 ADDITIONAL READINGS AND WEBSITES
 DEFINITION

disease

RATIONALE

GOALS

http://www.aapd.org/media/Policies_Guidelines/P_DentalHome.
pdf)

STEPS INVOLVED IN INFANT ORAL HEALTH CARE

2 The Handbook of Pediatric Dentistry

 individual needs

http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.
pdf

ANTICIPATORY GUIDANCE

developmental changes expected to occur between their children’s dental visits is an

ANTICIPATORY GUIDANCE: SUGGESTED CONTENT GUIDE

BIRTH TO THREE YEARS
Topic 6-12 months 12-24 months 24-36 months

The Handbook of Pediatric Dentistry 3

 ANTICIPATORY GUIDANCE: SUGGESTED CONTENT GUIDE
BIRTH TO THREE YEARS
Topic 6-12 months 12-24 months 24-36 months

ORAL HEALTH RISK ASSESSMENT

What to address What to ask

Medical history

4 The Handbook of Pediatric Dentistry

 What to address What to ask
Oral hygiene

Infant feeding

Dietary habits

Fluoride adequacy

The Handbook of Pediatric Dentistry 5

 What to address What to ask
Bacteria transmission

direct indirect vertical

horizontal

Demographic data

Teeth characteristics

Iatrogenic factors:

Salivary assays for MS: www.ivoclarviva.com

CARIES RISK ASSESSMENT FORM FOR 0-5 YEAR

OLDS*
High
Moderate Protective
Risk
Risk Factors Factors
Factors
Biological Factors

6 The Handbook of Pediatric Dentistry

 High
Moderate Protective
Risk
Risk Factors Factors
Factors
Protective Factors

Clinical Findings

Overall assessment of the child’s dental caries risk: High Moderate Low
*Based on 2011 AAPD Guideline on Caries-risk Assessment and Management for Infants, Children, and
Adolescents available at http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdf

The Handbook of Pediatric Dentistry 7

 EXAMPLE OF A CARIES MANAGEMENT PROTOCOL FOR
1-2 YEAR OLDS*
Risk
Diagnostics Interventions Restorative
Category
Fluoride Diet
Low Risk

Moderate
Risk

Moderate
Risk

High Risk

High Risk

Table Legends:

* Based on 2011 AAPD Guideline on Caries-risk Assessment and Management for Infants, Children, and
Adolescents available at http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdf

8 The Handbook of Pediatric Dentistry

RESPONSIBILITY OF NON-DENTAL PROFESSIONALS
REGARDING INFANT ORAL HEALTH CARE

Table 1. Caries-risk Assessment Form for 0-3 Year Olds 59,60

(For Physicians and Other Non-Dental Health Care Providers)

Factors High Risk Moderate Risk Protective

Biological
Mother/primary caregiver has active cavities Yes
Parent/caregiver has low socioeconomic status Yes
Child has >3 between meal sugar-containing snacks or beverages per day Yes
Child is put to bed with a bottle containing natural or added sugar Yes
Child has special health care needs Yes
Child is a recent immigrant Yes

Protective
Child receives optimally-fluoridated drinking water or fluoride supplements Yes
Child has teeth brushed daily with fluoridated toothpaste Yes
Child receives topical fluoride from health professional Yes
Child has dental home/regular dental care Yes

Clinical Findings
Child has white spot lesions or enamel defects Yes
Child has visible cavities or fillings Yes
Child has plaque on teeth Yes

Circling those conditions that apply to a specific patient helps the health care worker and parent understand the factors that contribute
to or protect from caries. Risk assessment categorization of low, moderate, or high is based on preponderance of factors for the
individual. However, clinical judgment may justify the use of one factor (eg, frequent exposure to sugar containing snacks or beverages,
visible cavities) in determining overall risk.

Overall assessment of the child’s dental caries risk: High Moderate Low

ADDITIONAL READINGS AND WEBSITES

The Handbook of Pediatric Dentistry 9

 Chapter 2: DENTAL DEVELOPMENT,
MORPHOLOGY, ERUPTION AND
RELATED PATHOLOGIES

Rebecca L. Slayton, Tegwyn H. Brickhouse

and Steven M. Adair

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/RS_DentGrowthandDev.pdf

11 DENTAL DEVELOPMENTAL STAGES

12 DENTAL DEVELOPMENTAL ANOMALIES
21 ABNORMALITIES OF COLOR
22 ERUPTION OF TEETH
23 ANOMALIES OF ERUPTION
28 TABLES (T)
30 ADDITIONAL READINGS AND WEBSITES
DENTAL DEVELOPMENTAL STAGES

Embryology

–
–
–

Morphologic Developmental Stages

The Handbook of Pediatric Dentistry 11

 Histophysiology (See Table on page 28)

–
–

–
–

–
–
–

–
–
–
–
–
–
–

–
–

DENTAL DEVELOPMENTAL ANOMALIES

Development Defects of Teeth: Anomalies of Number (Initiation) -

Hyperdontia

–
–

Anomalies of Number (Initiation) – Hypodontia (Oligodontia)

Syndromes with supernumerary teeth

–
–
–
12 The Handbook of Pediatric Dentistry
 –
–

–
–
–
–
–

–
–
–

–
–

–
–

–
–
–

–
–
–
–
–

Anomalies of Initiation and Proliferation - Hypodontia (Oligodontia)

and Anodontia

Conditions with hypodontia

–
–
–

The Handbook of Pediatric Dentistry 13

 –

–
–

–
–
–
–
–

–
–
–
–

–
–
–
–

–
–
–
–
–

–
–
–

–
–

–
–
–
–

Anomalies of Size (Proliferation)

–
–

Conditions with microdontia

14 The Handbook of Pediatric Dentistry

Conditions with macrodontia

Twinning/Conjoined Anomalies (Proliferation)

–
–

–
–

Anomalies of Size and Shape (Morphodifferentiation)

–
–
–
–

–
–
–

The Handbook of Pediatric Dentistry 15

 –
–

–
–
–
–

Syndromes with taurodontism

–
–
–

–
–

–
–

–
–

Anomalies of Structure (Histodifferentiation)

–
–

–
–
–

–
–
–
–
–

16 The Handbook of Pediatric Dentistry

 –
–
–
–
–

–
–
–
–
–
–
–

–
–
–
–
–
–

–
–
–
–
–
–
–

–
–
–
–
–
–
–
–

Anomalies of Structure (Apposition) - Enamel

–
–
–
–
–
–
–
The Handbook of Pediatric Dentistry 17
 –
–
–
–

–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–

–
–
–
–

Anomalies of Structure (Apposition) - Dentin

–
–
–
–
–
–
–
–
–

–
–
–

18 The Handbook of Pediatric Dentistry

 –

–
–

–
–
–
–
–
–

The Handbook of Pediatric Dentistry 19

 Anomalies of Structure (Apposition) - Cementum

–
–
–
–
–

–
–

Anomalies of Structure (Mineralization) - Enamel

»
»

–
–
–
–
–
–

Anomalies of Maturation - Enamel Structure

–
–
–
20 The Handbook of Pediatric Dentistry
 –
–
–
–
–
–
–

–
–
–

ABNORMALITIES OF COLOR

Intrinsic Stains

–
–
–
–

–
–

–
–
–
–
–
–
–
–

–
–

–
–
–
–

The Handbook of Pediatric Dentistry 21

 Extrinsic Stains

– Bacillus pyocaneus Aspergillis

–
–

–
–
–
–
–
–
–
–

ERUPTION OF TEETH (See Table page 28)

Theories of Eruption

Eruption Sequences

–
–
–

Stages of Eruption of Permanent Teeth

–
–
–

–
–

22 The Handbook of Pediatric Dentistry

 –
–
–
–

–
–
–
–

ANOMALIES OF ERUPTION

Timing

–
–
–
–
–
–
–
–
–

Teething

–
–
–

–
–

The Handbook of Pediatric Dentistry 23

 –
–
–
–
–
–

Cystic Development

–
–
–

–
–
–

Delayed Primary Exfoliation and Permanent Eruption

–
–
–
–

–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–

Accelerated Eruption of Primary and Permanent Teeth

–
–
–
–

24 The Handbook of Pediatric Dentistry

 –
–
–
–

Premature Exfoliation of Primary Teeth

–
–

–
–

–
–
–

–
–

–
–
–
–

–
–

Ectopic Eruption (Permanent Molars)

–
–
–
–
–
–

Ankylosis (Infraocclusion)

The Handbook of Pediatric Dentistry 25

 –
–
–
–

–
–

–
–
(prevalence variably reported)
–
–

–
–
–
–
–

–
–
–
–

26 The Handbook of Pediatric Dentistry

Maxillary Central Diastema

–
–
–

–
–

–
–

The Handbook of Pediatric Dentistry 27

 TABLES
Developmental Stages and Associated Anomalies

Stage Development Development

Dental Growth and Development

Primary Dentition
Calcification Formation Eruption Exfoliation
begins at complete at Maxillary Mandibular Maxillary Mandibular
Central incisors 4th fetal mo 18-24 mo 6-10 mo 5-8 mo 7-8 y 6-7 y
Lateral incisors 5th fetal mo 18-24 mo 8-12 mo 7-10 mo 8-9 y 7-8 y
Canines 6th fetal mo 30-39 mo 16-20 mo 16-20 mo 11-12 y 9-11 y
First molars 5th fetal mo 24-30 mo 11-18 mo 11-18 mo 9-11 y 10-12 y
Second molars 6th fetal mo 36 mo 20-30 mo 20-30 mo 9-12 y 11-13 y

Permanent Dentition
Calcification Crown (enamel) Roots Eruption*
begins at complete at complete at Maxillary Mandibular
Central incisiors 3-4 mo 4-5 y 9-10 y 7-8 y (3) 6-7 y (2)
Lateral incisors Maxilla: 10-12 mo 4-5 y 11 y 8-9 y (5) 7-8 y (4)
Mandible: 3-4 mo 4-5 y 10 y
Canines 4-5 mo 6-7 y 12-15 y 11-12y (11) 9-11y (6)
First premolars 18-24 mo 5-6 y 12-13 y 10-11y (7) 10-12 y (8)
Second premolars 24-30 mo 6-7 y 12-14 y 10-12 y (9) 11-13 y (10)
First molars Birth 30-36 mo 9-10 y 5.5-7 y (1) 5.5-7 (1a)
Second molars 30-36 mo 7-8 y 14-16 y 12-14 y (12) 12-13 y (12a)
Third molars Maxilla: 7-9 y 17-30 y (13) 17-30 y (13a)
Mandible: 8-10 y

*Figures in parentheses indicate order of eruption. Many otherwise normal infants do not conform strictly to the stated schedule.

Logan WHG, Kronfeld R. Development of the human jaws and surrounding structures from birth to the age of fifteen years. J Am Dent Assoc
1933;20(3):379-427. Copyright © 1933 American Dental Association. All rights reserved. Adapted 2003 by permission.

28 The Handbook of Pediatric Dentistry

 Chronology of the Human Dentition
AAPD Guideline: http://www.aapd.org/media/Policies_Guidelines/RS_
DentGrowthandDev.pdf
Tooth Eruption Charts: http://www.ada.org/public/topics/tooth_eruption.asp
Primary Dentition

( )

Permanent Dentition
Initiation Mineralization

–
–

The Handbook of Pediatric Dentistry 29

 ADDITIONAL READINGS AND WEBSITES

30 The Handbook of Pediatric Dentistry

Chapter 3: ORAL PATHOLOGY/ORAL
MEDICINE/SYNDROMES

Martha Ann Keels and Catherine M. Flaitz

33 INFANT SOFT TISSUE LESIONS

34 WHITE LESIONS
36 LOCALIZED GINGIVAL LESIONS
37 GENERALIZED GINGIVAL ENLARGEMENTS
39 PIGMENTATION
40 HEMORRHAGE AND/OR HEMORRHAGIC LESIONS
41 LIP AND BUCCAL SWELLINGS
42 MACROGLOSSIA
44 SUBLINGUAL SWELLINGS
45 SOFT TISSUE NECK SWELLINGS
46 PALATAL SWELLINGS
47 MAXILLARY AND/OR MANDIBULAR
ENLARGEMENTS
49 ORAL ULCERS/STOMATITIS
51 MULTILOCULAR RADIOLUCENCIES
53 SOLITARY OR MULTIPLE RADIOLUCENCIES WITH
INDISTINCT OR RAGGED BORDERS
 55 PERIAPICAL MIXED RADIOLUCENCIES-
RADIOPACITIES-DIFFERENTIAL DIAGNOSIS
56 PERICORONAL RADIOLUCENCIES
57 PERICORONAL RADIOLUCENCIES
CONTAINING RADIOPACITIES
58 RADIOLUCENCIES WITH DISTINCT BORDERS
59 CLEFT LIP AND PALATE
60 CRANIOSYNOSTOSIS
61 DWARFISM
62 ADDITIONAL READINGS AND WEBSITES

Abbreviations
HHV-Human Herpes Virus

HPV-Human Papilloma Virus

HSV-Herpes Simplex Virus
EBV-Epstein-Barr Virus

32 The Handbook of Pediatric Dentistry

INFANT SOFT TISSUE LESIONS
DIFFERENTIAL DIAGNOSIS
Common

–
–
–
–

–
–
–
–

–
–
–
–
–

–
–
–
–

–
–
–
–

The Handbook of Pediatric Dentistry 33

 –
–
–
–
–
Rare

–
–
–
–
–

–
–
–
–
–
–
–
–

–
–
–
–
–
–

–
–
–
–

WHITE LESIONS
DIFFERENTIAL DIAGNOSIS

Types of White Lesions

Common

–
–

–
–

34 The Handbook of Pediatric Dentistry

 –

–
–
–
–
–

–
–
–
–

–
–
–

–
–

–
–
–

–
–

–
–
–
–
–

–
–
–
–

–
–
–

–
–

–
–

The Handbook of Pediatric Dentistry 35

 –
–

–
–

White Lesion
Scrape

Scrapes off: Necrotic Does not scrape off : Keratotic

LOCALIZED GINGIVAL LESIONS

DIFFERENTIAL DIAGNOSIS
Common

–
–
–
–

–
–
–
–
–
–
–

–
–
–
–
–

–
–
–
–
–

36 The Handbook of Pediatric Dentistry

 –
–

–
–
–
–
–

–
–
–
–
–

–
–
–
–
–

–
–
–
–
–
–
–

–
–
–
–
–

GENERALIZED GINGIVAL ENLARGEMENTS

DIFFERENTIAL DIAGNOSIS
Common

–
–
–

–
–
The Handbook of Pediatric Dentistry 37
 –
–

–
–
–
Rare

–
–
–
–
–
–
–

–
–

–
–
–
–
–
–
–

–
–
–
–
–

38 The Handbook of Pediatric Dentistry

PIGMENTED LESIONS
DIFFERENTIAL DIAGNOSIS

–
–
–
–

–
–
–
–

–
–

The Handbook of Pediatric Dentistry 39

 –

PIGMENTED LESIONS

HEMORRHAGE AND/OR HEMORRHAGIC LESIONS

DIFFERENTIAL DIAGNOSIS
Common

Rare

–
–
–
–
–
–
–

40 The Handbook of Pediatric Dentistry

 –
–
–

–
–
–
–
–
–
–
–
–

LIP AND BUCCAL MUCOSA SWELLING

DIFFERENTIAL DIAGNOSIS
Common

–
–

–
–
–
–
–
–

–
–
–
–
–

The Handbook of Pediatric Dentistry 41

 Rare

–
–

–
–
–
–
–

–
–
–
–
–

–
–
–

–
–
–
–
–

–
–

MACROGLOSSIA
DIFFERENTIAL DIAGNOSIS
Common

–
–

42 The Handbook of Pediatric Dentistry

 –
–
–
–
–
–

–
–
–
–
–
–

–
–
–
–
–

–
–
–
–

–
–
–

–
–
–
–
–
–
–
–
–
–
–

–
–
–
–
–
–
–

–
–

The Handbook of Pediatric Dentistry 43

 –
–
–
–
–
–
–
–

–
–
–
–
–
–
–
–
–

–
–
–
–
–

SUBLINGUAL SWELLINGS
DIFFERENTIAL DIAGNOSIS

–
–
–
–
–
–

–
–
–
–
–
–

–
–
–

44 The Handbook of Pediatric Dentistry

 –
–
Rare

SOFT TISSUE NECK SWELLINGS

DIFFERENTIAL DIAGNOSIS
Common

–
–

–
–
–
–
Rare

– Bartonella henselae
–
–

–
–
–
–
–
–

–
–
–
–

The Handbook of Pediatric Dentistry 45

 –
–
–
–
–
–

–
–
–
–
–
–
–
–

–
– Mycobacterium
–
–

–
–
–

–
–
–

–
–
–

PALATAL SWELLINGS
DIFFERENTIAL DIAGNOSIS
Common

–
–
–

–
–
46 The Handbook of Pediatric Dentistry
 –
–
–

–
–
–
–
–
–
–

–
–

–
–
–

–
Rare

–
–
–
–
–
–

–
–

–
–
–
–
–

MAXILLARY AND/OR MANDIBULAR ENLARGEMENTS

DIFFERENTIAL DIAGNOSIS
Common

–
–
The Handbook of Pediatric Dentistry 47
 –

–
–

Rare

–
–
–
–

–
–
–
–

–
–
–
–
–
–

–
–
–

–
–
–
–
–
–

–
–
–
–
–
–
–
–

48 The Handbook of Pediatric Dentistry

ORAL ULCERS/STOMATITIS
DIFFERENTIAL DIAGNOSIS
Common

–
–

–
–
–
–

–
–
–
–
–
–
–
–
–

–
–
–
–

–
–
–
–
–
–

–
–
–
–
–

–
–

–
–
–

The Handbook of Pediatric Dentistry 49

 –
–
–
–

–
–

–
–
–
–
–
Rare

–
–
–
–
–
–
–

–
–
–
–

–
–
–

–
–

–
–
–
–
–
–

50 The Handbook of Pediatric Dentistry

 –
–
–
–
–
–
–

–
–
–

–
–
–

–
–

–
–

–
–
–
–
–
–
–

MULTILOCULAR RADIOLUCENCIES
DIFFERENTIAL DIAGNOSIS

–
–
–
–
–

–
–
–
–

–
–
–

The Handbook of Pediatric Dentistry 51

 –
–
–
–
–
–
–

–
–
–
–

–
–

–
–
–
–
–

–
–
–
–
–
–
–
–

Rare

–
–
–
–

–
–
52 The Handbook of Pediatric Dentistry
 –
–

–
–
–
–

–
–
–
–
–

SOLITARY OR MULTIPLE RADIOLUCENCIES WITH

INDISTINCT OR RAGGED BORDERS
DIFFERENTIAL DIAGNOSIS
Common

–
–
–
–
–
Rare

–
–
–

The Handbook of Pediatric Dentistry 53

 –
–
–
–
–

–
–
–

–
–
–
–
–
–
–

–
–
–
–
–

–
–
–
–
–

–
–
–
–
–
–
–

–
–
–
–

54 The Handbook of Pediatric Dentistry

PERIAPICAL MIXED RADIOLUCENCIES –
RADIOPACITIES
DIFFERENTIAL DIAGNOSIS
Common

–
–
–
–
–

–
–
–
–
–

–
–
–
–
–

–
Rare

–
–
–
–

–
–
–
–
–
–
–

–
–
–
–

The Handbook of Pediatric Dentistry 55

 –
–

–
–
–
–
–
–
–
–

–
–
–
–
–

–
–
–
–
–

–
–

–
–
–
–
–

–
–
–
–
–
–

PERICORONAL UNILOCULAR RADIOLUCENCIES

DIFFERENTIAL DIAGNOSIS
Common

–
–

–
–
–
56 The Handbook of Pediatric Dentistry
 –
–

–
–
–
–

–
–

–
–
–
–
–
–
Rare

–
–

–
–

PERICORONAL RADIOLUCENCIES CONTAINING

RADIOPACITIES
DIFFERENTIAL DIAGNOSIS
Common

–
–
–
–

–
–
–
–
–

–
–

The Handbook of Pediatric Dentistry 57

 –
–
–
–
–

–
–

–
–
–
–

–
–
–
–
–

PERIAPICAL OR CENTRAL RADIOLUCENCIES WITH

DISTINCT BORDERS
DIFFERENTIAL DIAGNOSIS
Common

–
–
–
–
–
–
–

–
–
–
–
–

58 The Handbook of Pediatric Dentistry

 –
–
–
–
–
–

–
–
–
–
Rare

–
–
–
–

CLEFT LIP AND PALATE

DIFFERENTIAL DIAGNOSIS

–
–
–
–
–

Rare

–
–
–
–
–

–
–

–
–

–
–
–
–
–
–
–
The Handbook of Pediatric Dentistry 59
 –
–
–

–
–
–
–
–
–
–
–
–
–
–

CRANIOSYNOSTOSIS
DIFFERENTIAL DIAGNOSIS
Rare

–
–
–
–
–
–
–
–
–
–
–
–

–
–
–
–
–
–
–
–
–

–
–

–
–
–

60 The Handbook of Pediatric Dentistry

 –
–
–

DWARFISM
DIFFERENTIAL DIAGNOSIS
Rare

–
–
–
–
–
–
–
–
–

–
–
–
–
–

–
–
–
–
–
–

–
–
–
–
–
–
–
–

–
–
–
–
–
–
–

The Handbook of Pediatric Dentistry 61

 –
–
–
–
–
–
–
–
–
–

–
–
–
–
–
–

ADDITIONAL READINGS AND WEBSITES

http://www.aapd.org/
members/photogallery/
http://medgen.genetics.utah.edu/photographs.htm (Accessed 8-2010)

http://www.ncbi.nlm.nih.gov/omim (Accessed 8-2010)

http://www.uiowa.edu/~oprm/AtlasWIN/AtlasFrame.html (Accessed 8-2010)

http://www.usc.edu/hsc/dental/opath/Diseases/index.html

http://www.oralpath.com/OralPathOLD2.htm (Accessed 8-2010)

62 The Handbook of Pediatric Dentistry

http://emedicine.medscape.com/ (Accessed 8-2010)

The Handbook of Pediatric Dentistry 63

 Chapter 4: FLUORIDE

John J. Warren and Michael Kanellis

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_FluorideTherapy.pdf

66 MECHANISM OF ACTION
66 FLUORIDE DENTIFRICES
66 FLUORIDE RINSES
66 SELF-APPLIED GELS
67 FLUORIDE VARNISH
67 PROFESSIONALLY APPPLIED GELS AND FOAM
67 FLUORIDATED WATER
67 DIETARY FLUORIDE
68 FLUORIDE SUPPLEMENTS (T)
68 FLUOROSIS ISSUE
68 ACUTE FLUORIDE TOXICITY
69 FLUORIDE CONCENTRATION OF COMMERCIAL
PRODUCTS (T)
69 FLUORIDE CONTENT OF INFANT FORMULAS (T)
 69 FLUORIDE COMPOUND/ION CONCENTRATION
CONVERSIONS (T)
70 PRESCRIPTION EXAMPLES (T)
70 FLUORIDE PRODUCTS
72 ADDITIONAL READINGS AND WEBSITES

The Handbook of Pediatric Dentistry 65

 MECHANISMS OF ACTION

–
–

–
–

–
–
–

FLUORIDE DENTIFRICES

–
–
–
–
–

FLUORIDE RINSES

–
–
–
–
–

SELF-APPLIED GELS & CREMES

–
–
–
–
–
–

–
–
–

66 The Handbook of Pediatric Dentistry

FLUORIDE VARNISH

–
–
–

PROFESSIONALLY APPLIED GELS/FOAM

–
–

FLUORIDATED WATER

–
–
–
–

DIETARY FLUORIDE

–
–
–
–
–
–

The Handbook of Pediatric Dentistry 67

 FLUORIDE SUPPLEMENTS

–
–
–
–
–
–
–

Current Supplementation Regimen

Water Fluoride Concentration (ppm)

Age <0.3 0.3-0.6 >0.6

* Dose in mg F ion

THE FLUOROSIS ISSUE

–
–
–
–

ACUTE FLUORIDE TOXICITY

–
–

68 The Handbook of Pediatric Dentistry

FLUORIDE CONCENTRATIONS OF
COMMERCIAL PRODUCTS

Fluoride concentration
and compound ion

Tray/ Brush On Products

FLUORIDE CONTENT OF COMMERCIAL INFANT

FORMULAS

Formula Fluoride Content

Source: Mead Johnson Inc., Ross Inc., Wyeth Inc.

PRESCRIPTION EXAMPLES

The Handbook of Pediatric Dentistry 69

 FLUORIDE PRODUCTS

–
–
–

–
–

70 The Handbook of Pediatric Dentistry

 –
–
–

–
–

–
–

–
–

The Handbook of Pediatric Dentistry 71

 –

ADDITIONAL READINGS AND WEBSITES

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm

72 The Handbook of Pediatric Dentistry

The Handbook of Pediatric Dentistry 73
 Chapter 5: RADIOLOGY

Richard M. Burke, Jr. and Jenny Ison Stigers

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/E_Radiographs.pdf

75 RADIOGRAPHIC PRINCIPLES
76 RADIATION HYGIENE
76 TECHNOLOGICAL ADVANCES
78 RISKS AND EFFECTS
78 TECHNIQUES/INDICATIONS
80 RECORDKEEPING/ADMINISTRATIVE
MANAGEMENT
80 ADDITIONAL READING AND WEBSITES (T)
RADIOGRAPHIC PRINCIPLES

–
–
–

The Handbook of Pediatric Dentistry 75

 RADIATION HYGIENE

–
–
–

–
–

–
–

TECHNOLOGICAL ADVANCES

76 The Handbook of Pediatric Dentistry

 –

–
–

The Handbook of Pediatric Dentistry 77

 RISKS AND EFFECTS

–
–

–
–

TECHNIQUES/INDICATIONS

78 The Handbook of Pediatric Dentistry

 –

The Handbook of Pediatric Dentistry 79

 –
–
–

–
–

–
–
–
–

RECORDKEEPING/ADMINISTRATIVE MANAGEMENT

ADDITIONAL READINGS AND WEBSITES

80 The Handbook of Pediatric Dentistry

The Handbook of Pediatric Dentistry 81
 Chapter 6: PERIODONTAL DISEASES
AND CONDITIONS

Ann Griffen and Purnima Kumar

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/E_Plaque.pdf
http://www.aapd.org/media/Policies_Guidelines/E_PerioTherapy.pdf
http://www.aapd.org/media/Policies_Guidelines/E_PeriodontalDisease.pdf

83 GINGIVAL DISEASE
85 CHRONIC PERIODONTITIS
85 AGGRESSIVE PERIODONTITIS
86 PERIODONTITIS AS A MANIFESTATION OF
SYSTEMIC DISEASE
88 DEVELOPMENTAL OR ACQUIRED DEFORMITIES
OR CONDITIONS
89 CLINICAL PERIODONTAL EXAMINATION
89 ADDITIONAL READINGS AND WEBSITES
GINGIVAL DISEASE
Plaque-Induced Gingivitis

–
–
–

–
–
–

–
–
–
–

Plaque-Induced Gingival Enlargement

–
–
–

–
–
Dental Management

The Handbook of Pediatric Dentistry 83

 –

Pyogenic Granuloma (Pregnancy Tumor)

Gingival Abscess

Dental Management

Pericoronitis

Dental Management

Vitamin C-Associated Gingivitis

–
–
–
Dental Management

Acute Necrotizing Ulcerative Gingivitis (ANUG)

–
–
–

–
–
–
Dental Management

84 The Handbook of Pediatric Dentistry

CHRONIC PERIODONTITIS

–
–

–
–

–
– Porphyromonas gingivalis

–
–

–
–
–

–
–
Insulin-Dependent Diabetes Mellitus (Type I) and Chronic Periodontitis

Dental Management

AGGRESSIVE PERIODONTITIS (FORMERLY “EARLY

ONSET PERIODONTITIS”)
Localized Aggressive Periodontitis (LAP) in the primary dentition (formerly
prepubertal periodontitis [PPP])

–
–
–
–
–
–
–

–
–
– Actinobacillus actinomycetemcomitans

The Handbook of Pediatric Dentistry 85

 Dental Management

–
–
–
–
–
–

– Actinobacillus actinomycetemcomitans

Dental Management

–
– Actinobacillus actinomycetemcomitans

– Actinobacillus
actinomycetemcomitans
–

Generalized Aggressive Periodontitis

PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC

DISEASES
Hypophosphatasia

–
–
–

–
–

86 The Handbook of Pediatric Dentistry

 –
–

–
–

–
Dental Management

Leukocyte Adhesion Defect (LAD)

Dental Management

Papillon-LeFèvre Syndrome

–
–

–
– Actinobacillus actinomycetemcomitans
Dental Management

Down Syndrome

–
–
Chediak-Higashi Syndrome

The Handbook of Pediatric Dentistry 87

 Neutropenia

–
–
–
–

–
–
–
–

Dental Management

Langerhans Cell Histiocytosis (formerly “histiocytosis X”)

Acute Leukemia

DEVELOPMENTAL OR ACQUIRED DEFORMITIES OR

CONDITIONS

–
–
–

–
–
–
–

–
–

88 The Handbook of Pediatric Dentistry

 –

–
–

CLINICAL PERIODONTAL EXAMINATION

–
–
–
–
–
–

–
–

–
–

–
–
–
–

ADDITIONAL READINGS AND WEBSITES

The Handbook of Pediatric Dentistry 89

 Chapter 7: PULP THERAPY IN
PRIMARY AND YOUNG
PERMANENT TEETH

Michael J. Casas and Anna B. Fuks

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_Pulp.pdf

91 CLINICAL AND RADIOGRAPHIC ASSESSMENT OF

PULP STATUS (T)
92 VITAL PULP THERAPY FOR PRIMARY TEETH (T)
94 NON-VITAL PULP THERAPY FOR PRIMARY
TEETH (RX)
96 VITAL PULP THREATMENT IN YOUNG
PERMANENT TEETH
97 NON-VITAL PULP THERAPY FOR YOUNG
PERMANENT TEETH
98 ADDITIONAL READINGS AND WEBSITES
CLINICAL AND RADIOGRAPHIC ASSESSMENT OF
PULP STATUS

Candidate teeth for vital pulp therapy

Candidate teeth for non-vital pulp therapy or extraction

The Handbook of Pediatric Dentistry 91

 Confounding factors in diagnosis of pulp status

Reliability of clinical assessments

Primary tooth Immature Mature

permanent tooth permanent tooth
– + +
+ + ++
+ + ++

VITAL PRIMARY TOOTH PULP THERAPY

Treatment objectives

Protective base

Indirect Pulp Treatment (IPT)

Direct Pulp Capping (DPC)

92 The Handbook of Pediatric Dentistry

 Pulpotomy

Technique Method of Acceptable Comments

action outcomes

The Handbook of Pediatric Dentistry 93

 Formocresol Pulpotomy (FC)

–
–
–

Ferric sulfate (FS)

Mineral trioxide aggregate (MTA)

Vital primary tooth root canal therapy

NON-VITAL PULP THERAPY FOR PRIMARY TEETH

Treatment options

Pulpectomy

–
–
–

94 The Handbook of Pediatric Dentistry

 –
–
–

–
–
–
–

Zinc oxide and eugenol

Calcium hydroxide Ca(OH)2

Kri 1 Paste (Pharmachemie, Zurich, Switzerland)

–
–
–
–

–
–
–
vs
– vs
–
Vitapex (Neo dental Chemical Products, Tokyo, Japan)

The Handbook of Pediatric Dentistry 95

 Maisto’s paste

Empiric therapy for acute infection

Evidence for non-vital primary pulp therapy

New concept: lesion sterilization and tissue repair using antibacterial drugs

VITAL PULP TREATMENT FOR YOUNG PERMANENT

TEETH
Protective base

Indirect pulp therapy (IPT)

Direct pulp caps (DPC)

Pulpotomy
Objectives of pulpotomy (Ideal)

96 The Handbook of Pediatric Dentistry

 Objectives vary with treatment choice

Ca(OH)2

Apexogenesis

Partial pulpotomy (Cvek)

Partial pulpectomy

NON-VITAL PULP THERAPY FOR YOUNG PERMANENT

TEETH
Objectives

2
: Frank technique)

–
–
–

The Handbook of Pediatric Dentistry 97

 Apical plug with MTA

Revascularization technique (early investigations)

–
–

–
Evaluation of success

ADDITIONAL READINGS AND WEBSITES

98 The Handbook of Pediatric Dentistry

 Chapter 8: RESTORATIVE DENTISTRY

Joel H. Berg and Kevin J. Donly

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_Restorative.pdf

100 AMALGAM (T)

101 CAVITY LINERS
101 CAVITY VARNISHES
102 STAINLESS STEEL CROWNS (T)
102 RESIN-BASED COMPOSITES AND
BONDING AGENTS
104 RESIN INFILTRATION
105 GLASS IONOMER CEMENTS
106 CAVITY PREPARATION IN PRIMARY TEETH
107 MANAGING OCCLUSAL SURFACES OF YOUNG
PERMANENT TEETH (T)
107 OCCLUSAL SEALANTS
108 ADDITIONAL READINGS AND WEBSITES
 AMALGAM
Advantages

Disadvantages

Indications and Objectives (AAPD)

Bonded Amalgam

Mercury Issue

Reducing Occupational Exposure to Mercury

100 The Handbook of Pediatric Dentistry

 Durability in Primary Teeth
Study Survival Rate (%) Time Period

50

Kilpatrick, J Dent 21:57, 1993.

Summary of Mean Survival Time (MST) Prediction

Patient Age at
Study MST
Placement

CAVITY LINERS

–
–
–
–

–
–
–
–

CAVITY VARNISHES

The Handbook of Pediatric Dentistry 101

 STAINLESS STEEL CROWNS
Alloy: chrome steel

Properties

Alloy: nickel-chrome (Ion crowns, 3M™)

Indications and objectives (AAPD)

Laminated anterior stainless steel crowns

RESIN-BASED COMPOSITES AND BONDING AGENTS

Fine particle (often contains distributions of > 2 sizes of particles

102 The Handbook of Pediatric Dentistry

 Objectives (AAPD)

Concerns with posterior composites

Strip crowns

Bisphenol A Controversy

Indications

Bonding agents—enamel

Bonding agents—dentin

The Handbook of Pediatric Dentistry 103

 Dentinal tubule structure affects bonding surface

Smear layer

Conditioners

Primers

Third generation bonding agents

Fourth generation bonding agents

Fifth generation bonding agents

Self-etching adhesives

RESIN INFILTRATION

104 The Handbook of Pediatric Dentistry

GLASS IONOMER CEMENTS
Properties: GI advantages

Properties: GI disadvantages

VLC GI/resin hybrid restorative materials

Interim Therapeutic Restoration (ITR)

SEE: http://www.aapd.org/media/Policies_Guidelines/P_ART.pdf

The dental literature supports the use of glass ionomer cement systems in the
following situations:

–
–
–

The Handbook of Pediatric Dentistry 105

 CAVITY PREPARATION IN PRIMARY TEETH
Thinner enamel and dentin than permanent teeth

Pulps are larger in relation to crown

Pulp horns are closer to DEJ (especially mesiofacial)

Enamel rods in gingival third extend in occlusal direction from DEJ

Greater constriction of crown at CEJ, more prominent cervical constriction

Whiter in color

Dentin lighter in color

Relatively narrower occlusal table

Common Errors in Class II Cavity Preparations for Primary Teeth

106 The Handbook of Pediatric Dentistry

MANAGING OCCLUSAL SURFACES OF YOUNG
PERMANENT TEETH

Occlusal Surface Clinical Findings Treatment

Recommendations*
Sound

Questionable

Carious

* Treatment recommendations are based on three assumptions: the proximal surfaces are sound, the tooth can
be adequately isolated, and the tooth has been erupted less than four years.

OCCLUSAL SEALANTS

The Handbook of Pediatric Dentistry 107

 ADDITIONAL READINGS AND WEBSITES

108 The Handbook of Pediatric Dentistry

 Chapter 9: TRAUMA

Dennis J. McTigue and Sarat Thikkurissy

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_Trauma.pdf

110 DIAGNOSTIC WORKUP

110 SAMPLE TRAUMA NOTE (T)
110 TRIAGE (T)
111 EXAMINATION (T)
112 RADIOGRAPHS
112 FUNDAMENTAL ISSUES
113 TREATMENT ALGORITHMS
116 COMPLICATIONS
116 SOFT TISSUE INJURIES
116 ORAL ELECTRICAL BURNS (T)
117 ADDITIONAL READINGS AND WEBSITES
 DIAGNOSTIC WORKUP

–
–

–
–

– http://www.aapd.org/media/Policies_
Guidelines/G_Trauma.pdf

SAMPLE TRAUMA NOTE

TRIAGE

–
–

–
–

110 The Handbook of Pediatric Dentistry

 GLASGOW COMA SCALE
FINDING RATING

4
3
2
1

4
3
2
1

4
3
2
1

EXAMINATION

–
–

The Handbook of Pediatric Dentistry 111

 Cranial Nerve Examination

RADIOGRAPHS

FUNDAMENTAL ISSUES
Primary Teeth

Permanent Teeth:

112 The Handbook of Pediatric Dentistry

 COMPLICATIONS

SOFT TISSUE INJURIES

ORAL ELECTRICAL BURNS

* For facial burns that will require grafts or have dressings, consider Ivey loops on teeth to retain endotracheal
tube

Perioral Dimensions 12, 24, 36 Months of Age (mm)

CLOSED MOUTH OPEN MOUTH
BREADTH BREADTH INTER-
AGE (Inter-commissure) (Inter-commissure) INCISAL
12
24
36

116 The Handbook of Pediatric Dentistry

ADDITIONAL READINGS AND WEBSITES

The Handbook of Pediatric Dentistry 117

 Chapter 10: GROWTH AND
DEVELOPMENT/MANAGEMENT
OF THE DEVELOPING OCCLUSION

Ronald A. Bell and Jeffrey A. Dean

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_DevelopDentition.pdf

120 BASICS OF CRANIOFACIAL GROWTH (T)

124 CLINICAL EVALUATION OF THE PRIMARY
DENTITION
125 MANAGEMENT OF THE PRIMARY DENTITION
SPACE MAINTENANCE
POSTERIOR CROSSBITE
ANTERIOR CROSSBITE
NON-NUTRITIVE SUCKING HABITS (NNS)
AIRWAY COMPROMISE/MOUTHBREATHING
127 CLINICAL EVALUATION OF THE MIXED
DENTITION
 129 MANAGEMENT OF THE MIXED DENTITION
OVERVIEW OF SPACE SUPERVISION/GUIDANCE OF ERUPTION
SPACE MAINTENANCE
REGAINING LOST POSTERIOR SPACE
MANDIBULAR INCISOR CROWDING/ARCH LENGTH
DISCREPANCY
ECTOPIC ERUPTION OF FIRST PERMANENT MOLARS
DENTAL/FUNCTIONAL ANTERIOR CROSSBITE
ANTERIOR OPENBITE WITH EXTRAORAL HABIT
POSTERIOR CROSSBITE
MAXILLARY CANINE ERUPTIVE DISPLACEMENT
CONGENITALLY MISSING PERMANENT TEETH
ANKYLOSED TEETH
SUPERNUMERARY TEETH
138 TREATING SKELETAL MALOCCLUSIONS IN THE
MIXED DENTITION
OVERVIEW
TRANSVERSE BASAL ARCH EXPANSION
ANTEROPOSTERIOR CLASS II MALOCCLUSION > RETRUSIVE
MANDIBLE > FUNCTIONAL APPLIANCE
ANTEROPOSTERIOR CLASS II MALOCCLUSION >
PROTRUSIVE MANDIBLE > DIRECTED HEADGEAR
ANTEROPOSTERIOR CLASS II MALOCCLUSION WITH
ACCEPTABLE A-P SKELETAL/PROFILE RELATIONSHIPS
ANTEROPOSTERIOR CLASS III MALOCCLUSION
141 ADDITIONAL READINGS AND WEBSITES

The Handbook of Pediatric Dentistry 119

 BASICS OF CRANIOFACIAL GROWTH
Types Of Bone Formation (Bone apposition generally occurs in osteogenic areas under
tension, not pressure)

–
–
Growth of Facial Components

–
contact areas, sutures
–

–
– Spheno-occipital considered principal

–
– remodeling-cortical drift
displacement)
–

–
–

Facial Growth Patterns

–
–

– Hypodivergent/brachyfacial:

120 The Handbook of Pediatric Dentistry

 – Hyperdivergent/dolichofacial

– least

Facial Analysis with Lateral Cephalometrics

–
–
–

*Values from composite assessments of longitudinal growth studies involving male and female Caucasians.
Adult values represented in females at 14 years and males at 18 years of age; from Bishara, Am J Ortho,
Jan 1981

MAXILLA 9 y.o. (x ± sd) Adult (x ± sd)

MANDIBLE

BASAL RELATIONSHIP: MAXILLA TO MANDIBLE

The Handbook of Pediatric Dentistry 121

 FACIAL TYPE/ 9 y.o. (x ± sd) Adult (x ± sd)
GROWTH PATTERN

MAXILLARY DENTITION

MANDIBULAR DENTITION

MAXILLARY TO MANDIBULAR DENTITION

FACIAL/SOFT TISSUE PROFILE

Legend for Ceph Landmarks Illustration:

122 The Handbook of Pediatric Dentistry

 –

–
–

The Handbook of Pediatric Dentistry 123

 CLINICAL EVALUATION OF THE PRIMARY DENTITION
Eruption Timing and Sequencing

Primary Dentition Occlusion

–
dentition
–

124 The Handbook of Pediatric Dentistry

 –
–
–
–

dentition
–
–
–
dentition

–
–

–
–
–

MANAGEMENT OF THE PRIMARY DENTITION

Premature Loss of Primary Teeth - Space Maintenance

The Handbook of Pediatric Dentistry 125

 –

–
–
Posterior Crossbites in the Primary Dentition

include:

126 The Handbook of Pediatric Dentistry

 Anterior Crossbites in the Primary Dentition

Non-nutritive Digit Sucking Habits (NNS)

Airway Compromise/Mouthbreathing

–
–

CLINICAL EVALUATION OF THE MIXED DENTITION

Eruption Timing and Sequencing

The Handbook of Pediatric Dentistry 127

 –

Normal Mixed Dentition Occlusion and Alignment

–
–

– -
and -
–

spaces)

»
»

128 The Handbook of Pediatric Dentistry

 –

MANAGEMENT OF THE MIXED DENTITION

Overview of Space Supervision/Guidance of Eruption Concepts *

and interceptive procedures beyond “preventive” interventions

space loss

The Handbook of Pediatric Dentistry 129

 –

positioning
–

Space Maintenance

Regaining of Lost Posterior Space

–
appliance
–
Mandibular Incisor Crowding—Arch Length Discrepancies

–
–

include:

130 The Handbook of Pediatric Dentistry

 incisors

distorted incisor positioning

patterns

The Handbook of Pediatric Dentistry 131

 Ectopic Eruption of First Permanent Molars

–
–

Dental/Functional Anterior Crossbite

constriction

–
aspect present

132 The Handbook of Pediatric Dentistry

 –
–

local etiology
cooperation

Anterior Openbite With Extraoral Habit

dentition

–
–

patient age and cooperation

The Handbook of Pediatric Dentistry 133

 –

–
Posterior Crossbite In The Mixed Dentition

–
–

results in:

side
–

positions
–

patient age

134 The Handbook of Pediatric Dentistry

 –

Maxillary Canine Eruptive Displacement

canines atypical

palatal canines
–

Congenitally Missing Permanent Teeth (excluding third molars)

The Handbook of Pediatric Dentistry 135

 –

patterns

Ankylosed Teeth

–
–

136 The Handbook of Pediatric Dentistry

 –

Supernumerary Teeth

–
position properly

The Handbook of Pediatric Dentistry 137

 TREATING SKELETAL MALOCCLUSIONS IN THE
MIXED DENTITION
Overview of Dentofacial Orthopedics

Transverse basal arch expansion

Anteroposterior Class II malocclusion > Retrusive Mandible > Functional

Appliances

138 The Handbook of Pediatric Dentistry

 –

cooperation
–

appliance

Anteroposterior Class II Malocclusion > Protrusive Maxilla > Directed

Headgear

The Handbook of Pediatric Dentistry 139

 Relationships

–
appliances
–
–
discrepancy
–

elastics
Anteroposterior Class III Malocclusion

studies

period
140 The Handbook of Pediatric Dentistry
 patterns

ADDITIONAL READINGS AND WEBSITES

The Handbook of Pediatric Dentistry 141

 Chapter 11: RECORD KEEPING
AND FORMS

Paul S. Casamassimo and Arthur J. Nowak

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_Recordkeeping.pdf
http://www.aapd.org/media/Policies_Guidelines/G_InformedConsent.pdf
http://www.aapd.org/media/Policies_Guidelines/P_PatientBillofRights.pdf

143 GENERAL INFORMATION AND PRINCIPLES

143 PATIENT INFORMATION SECTION
143 MEDICAL AND DENTAL HISTORY
144 EXAMINATION AND TREATMENT PLANNING
145 TRAUMA ASSESSMENT
145 PHARMACOLOGICAL/BEHAVIOR GUIDANCE
146 PREVENTIVE RECALL
146 RESTORATIVE
146 COMPREHENSIVE ORTHODONTIC
146 CONSULTATION REQUEST
147 INFORMED CONSENT
148 CONFIDENTIALITY AND HIPAA
148 ADDITIONAL READING AND WEBSITES
GENERAL INFORMATION AND PRINCIPLES

Electronic Dental Record (EDR)

PATIENT INFORMATION SECTION

MEDICAL AND DENTAL HISTORY

The Handbook of Pediatric Dentistry 143

 EXAMINATION AND TREATMENT PLANNING

144 The Handbook of Pediatric Dentistry

TRAUMA ASSESSMENT

PHARMACOLOGICAL/BEHAVIOR MANAGEMENT

The Handbook of Pediatric Dentistry 145

 PREVENTIVE/RECALL

RESTORATIVE

COMPREHENSIVE ORTHODONTIC

146 The Handbook of Pediatric Dentistry

CONSULTATION REQUEST

INFORMED CONSENT

The Handbook of Pediatric Dentistry 147

 emergencies

CONFIDENTIALITY AND HIPAA

http://www.hhs.gov/ocr/privacy/

ADDITIONAL READING AND WEBSITES

AAPD Trauma Form
http://www.aapd.org/media/Policies_Guidelines/G_Trauma.pdf
AAPD Caries Risk Assessment Tool
http://www.aapd.org/media/Policies_Guidelines/RS_CAT.pdf
Health Insurance Portability and Accountability Act
http://www.hhs.gov/ocr/hipaa/
148 The Handbook of Pediatric Dentistry
 
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286
The Handbook of Pediatric Dentistry 149
Record Transfer 249 5/1/07, 11:20 AM
 Chapter 12: INFECTION CONTROL

Terrence Chan and Gail E. Molinari

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/P_InfectionControl.pdf

151 GUIDELINES FOR EXPOSURE DETERMINATION

AND PREVENTION
152 USE OF PERSONAL PROTECTIVE EQUIPMENT (T)
152 INFECTION CONTROL CATEGORIES OF PATIENT
CARE INSTRUMENTS (T)
153 METHOD FOR STERILIZING AND DISINFECTING
PATIENT-CARE ITEMS AND ENVIRONMENTAL
SURFACES (T)
155 MAJOR METHODS OF STERILIZATION (T)
156 GUIDE FOR SELECTION OF APPROPRIATE
DISINFECTION METHODS FOR ITEMS
TRANSPORTED TO OR FROM THE
DENTAL LABORATORY (T)
157 ADDITIONAL READINGS AND WEBSITES
GUIDELINES FOR EXPOSURE DETERMINATION AND
PREVENTION
Listed below are the minimum requirements recommended during controlled situations
to protect the health care worker from potentially infectious agents. These lists are not all
inclusive, so judgment is required on the part of the health care worker to assess the need
for additional barrier protection in less controlled situations.

– immunocompromised
– those with infectious diseases ( tuberculosis)
– those potentially infective ( e.g., exposed to chickenpox )

– refer to your hospital policy and procedure manual

– recap needles with one-handed/scoop or use recapping device

– dispose of sharps in puncture-proof container
– don’t bend needles

– high speeds
clean and sterilize after each patient
2
O for 20-30 secs after each patient
2
O line
– slow speeds
clean and sterilize all attachments (except motor); disinfect motor cover
2
O syringe
sterilize tips or use disposables;
disinfect/sterilize
syringe handles

–
CFU/mL
–
self-contained water systems combined with chemical treatment

autoclavable water delivery systems

other water treatment strategies including UV, reverse osmosis, super-heating
of entrance water
combinations of the above
–
contained system will not eliminate bacterial contamination in treatment water if

– the majority of recently manufactured dental units are engineered to prevent

minimum of 20-30 seconds after each patient is recommended

– periodic monitoring of dental unit water quality should occur

– 2
O before removal from line (bur in)
– clean and dry instrument
– apply hand piece cleaner and /or lubricant if required
– expel excess lubricants (bur in)
The Handbook of Pediatric Dentistry 151
 –
– bag and heat process hand piece
– 2
O lines (20-30 secs) in hose before attaching
– open bag (lube if needed) attach hose and expel excess lube (bur in)

USE OF PERSONAL PROTECTIVE EQUIPMENT

Situation Hand Glove Fluid Goggles/
hygiene Resistant Mask
Gowns
Clean surfaces contaminated x x x x

Contact with blood saliva, x x x x

mucous membranes

Contact with blood soiled x x x x

Examining all oral lesions x x x

x x x x

is likely (cavity preparation,

prophylaxis)

Performing decontamination x x x x
procedures on soiled
instruments

INFECTION CONTROL CATEGORIES OF PATIENT

CARE INSTRUMENTS
Category Dental instrument or item
Critical Penetrates soft tissue, contact
bone, enters into or contacts the scalers, scalpel blades, surgical
bloodstream or other normally dental burs
sterile tissue
Contacts mucous membranes or
nonintact skin; will not penetrate condenser, reusable dental
soft tissue, contact bone, enter impression trays, dental hand
into or contact the bloodstream pieces*
or other normally sterile tissue
Contacts intact skin
pressure cuff, face bow, pulse
oximeter

* Although dental hand pieces are considered a semi critical item, they should always be heat-sterilized
between uses and not high-level disinfected

152 The Handbook of Pediatric Dentistry

METHOD FOR STERILIZING AND
DISINFECTING PATIENT-CARE ITEMS AND
ENVIRONMENTAL SURFACES
Health-care application
Process Result Method Examples Type of Environ-
patient- mental
care item surfaces

microorgan- automated heat, unsatu- tolerant applicable

isms, includ- - rated chemical critical and
ing bacterial perature vapor semi-critical
spores

Low tem- Ethylene oxide

perature gas, plasma sensitive
sterilization critical and
semi-critical
Liquid Chemical
immersion sterilants sensitive
Glutaralde- critical and
hyde, glu- semi-critical
taraldehydes
with phenol,
hydrogen per-
oxide, hydrogen
peroxide with
peracetic acid,
peracetic acid

disinfection microorgan- automated disinfector sensitive applicable

isms, but not semi-critical
necessarily
high num-
bers of bac-
terial spores

Liquid Chemical
immersion sterilants/
high-level
disinfectants
Glutaralde-
hyde, glu-
taraldehydes
with phenol,
hydrogen per-
oxide, hydrogen
peroxide with
peracetic acid,
ortho-phthalal-
dehyde

The Handbook of Pediatric Dentistry 153

 Health-care application
Process Result Method Examples Type of Environ-
patient- mental
care item surfaces
Intermedi- Liquid Clinical con-
ate level vegetative contact Environmental with visible tact surfaces;
disinfection bacteria and Protection blood blood spills
the majority Agency ( EPA)- on house-
of fungi registered keeping sur-
and viruses. hospital faces
Inactivates disinfectant
Mycobacterium with label
bovis. claim of
necessarily tuberculocidal
capable activity (e.g.,
of killing chlorine
bacterial containing
spores. products,
quaternary
ammonium
compounds
with alcohol,
phenolics,
iodophors,
EPA-registered
chlorine-based
product)

Low -level Liquid EPA-registered Clinical con-

disinfection majority of contact hospital disin- without tact surfaces;
vegetative fectant with no visible blood housekeep-
bacteria, label claim re- ing surfaces
certain fungi garding tuber-
and viruses. culocidal activ-
ity. The Occu-
inactivate
Mycobacte-
rium bovis Administration
also requires
label claims
of human im-

potency for
clinical contact
surfaces(e.g.,
quaternary am-
monium com-
pounds, some
phenolics, some
iodophors

154 The Handbook of Pediatric Dentistry

MAJOR METHODS OF STERILIZATION
Method Temp Pressure Cycle Advantage Disadvantage
Time
121°C Corrosion, dulling
Autoclave around, good of unprotected
penetration, instruments,
wide range of packages may
materials remain wet
160°C n/a 2 hours Long cycle
Oven (320°F) corrode or dull time, destroys
instruments, heat-labile items
no toxic or (plastics)
170°C n/a 1 hour hazardous
(340°F) chemicals, low
cost per cycle
n/a 12 min for Cannot sterilize
Transfer wrapped and items are dry, liquids, damage
6 min for small capacity to heat-labile
unwrapped, items, cannot
unwrapped open door during
items quickly cycle
contaminate
Unsaturated 131°C 20 psi 30 min Uses toxic or
Chemical (270°F) time, less hazardous
Vapor corrosive on chemicals,
instruments requires fume
ventilation,
destroys heat-
sensitive plastics
Ethylene n/a 10-16 hours Very long cycle
Oxide most materials time, uses toxic
including / hazardous
temp. dental chemicals,
appliances / requires special
instruments ventilation

The Handbook of Pediatric Dentistry 155

 GUIDE FOR SELECTION OF APPROPRIATE
DISINFECTION METHODS FOR ITEMS TRANSPORTED
TO OR FROM THE DENTAL LABORATORY

Item Method Recommended Comments

disinfectants
Casts Chlorine
immerse compounds or be prepared using
iodophors slurry water
(saturated calcium
sulfate)
Probably should not
be disinfected until
fully set ( 24 hours )
Impressions Immersion
disinfection reusable impression
preferred trays

after use
Irreversible Chlorine
hydrocolloid immersion with compounds or immersion in
(alginate) caution. Use only iodophors glutaraldehydes has
disinfectants with been shown to be
short-term exposure acceptable; but time
times (no more than is inadequate for
10 min for alginates). disinfection
Impression Iodophors or Phenolic sprays can
compound chlorine compounds be used
Prostheses Immerse in Clean “old”
disinfectant Use after disinfection prostheses by
caution to avoid scrubbing with hand
corrosion of wash antiseptic or
metal Can also sonication before
be sterilized by disinfection
exposure to ethylene
oxide gas
Chlorine
porcelain) compounds or after disinfection;
iodophors store in diluted
mouthwash

Note: Exposure time to disinfectant should be that recommended by the disinfectant manufacturer. All items
must be thoroughly rinsed (15 seconds minimum ) under running tap water after disinfection.
From Merchant VA: Dental laboratory infection control: OIC update, Dent Learn Syst 3:1-8, 1995.

156 The Handbook of Pediatric Dentistry

ADDITIONAL READINGS AND WEBSITES

2. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

The Handbook of Pediatric Dentistry 157

 Chapter 13: BEHAVIOR GUIDANCE

Stephen Wilson

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_BehavGuide.pdf
http://www.aapd.org/media/Policies_Guidelines/G_Nitrous.pdf
http://www.aapd.org/media/Policies_Guidelines/G_Sedation.pdf
http://www.aapd.org/media/Policies_Guidelines/G_AnesthesiaPersonnel.pdf

159 CLASSIC BEHAVIOR THEORIES

159 CONTEMPORARY BEHAVIOR THEORIES
159 BEHAVIOR GUIDANCE PRINCIPLES
160 BEHAVIOR GUIDANCE TECHNIQUES
160 SEDATION (T)
162 SEDATION ROUTES
163 MEDICATIONS
164 PRE-SEDATION PREPARATION
165 MONITORING PRINCIPLES
166 EMERGENCIES
167 ADDITIONAL READING AND WEBSITES
CLASSIC BEHAVIOR THEORIES

–
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CONTEMPORARY BEHAVIOR THEORIES

BEHAVIOR MANAGEMENT PRINCIPLES

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The Handbook of Pediatric Dentistry 159

 BEHAVIOR MANAGEMENT TECHNIQUES

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SEDATION

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160 The Handbook of Pediatric Dentistry

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The Handbook of Pediatric Dentistry 161

 Level of Cognitive Physiological Monitor Personnel
Sedation Function Function
Minimal

Moderate

Deep

SEDATION ROUTES
Inhalation
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162 The Handbook of Pediatric Dentistry

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MEDICATIONS

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The Handbook of Pediatric Dentistry 163

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PRESEDATION PREPARATION

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164 The Handbook of Pediatric Dentistry

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MONITORING PRINCIPLES

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The Handbook of Pediatric Dentistry 165

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EMERGENCIES
AAPD Resource: http://www.aapd.org/media/Policies_Guidelines/RS_
MedEmergencies.pdf

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166 The Handbook of Pediatric Dentistry

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The Handbook of Pediatric Dentistry 167

 Chapter 14: PAIN CONTROL

Kaaren G. Vargas

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_LocalAnesthesia.pdf

169 INDICATIONS
169 TECHNIQUES OF LOCAL ANESTHESIA
169 MAXIMUM RECOMMENDED DOSAGES (T)
170 LOCAL ANESTHETIC OVERDOSE
170 COMPLICATIONS OF LOCAL ANESTHESIA
171 ANALGESIA FOR CHILDREN
172 ADDITIONAL READINGS AND WEBSITES
INDICATION

TECHNIQUES OF LOCAL ANESTHESIA

–
–

MAXIMUM RECOMMENDED DOSAGES

Local Anesthestics
Drug Mg/kg Mg/lb Absolute
Maximum Dose

4.4
4.4

3.6

The Handbook of Pediatric Dentistry 169

 Lidocaine
MAXIMUM DOSE
PATIENT WEIGHT MG NO. CARTRIDGES
(KG/LB)
44
66
88

3.6
4.8

7.3
8.3

LOCAL ANESTHETIC OVERDOSE

–
–

–
–

COMPLICATIONS OF LOCAL ANESTHESIA

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170 The Handbook of Pediatric Dentistry

 ANALGESIA FOR CHILDREN
TRANSLATIONS OF WONG-BAKER FACES PAIN RATING SCALE*

0–5 coding 0 1 2 3 4 5
0-10 coding 0 2 4 6 8 10

ENGLISH No hurt Hurts little Hurts little Hurts even Hurts whole Hurts worst
bit more more lot

SPANISH
– No duele Duele un poco Duele un Duele Duele mucho Duele el
– poco más mucho más máximo

FRENCH
– Pas mal Un petit Un peu plus Encore Très mal Très très mal
– peu mal mal plus mal

ITALIAN – Non fa Fa male Fa male Fa male Fa molto male Fa maggior-

– male un poco un po di piu ancora di piu mente male

PORTUGUESE Não doi Doi um pouco Doi um Doi muito Doi muito mais Doi o máximo
Analgesics Commonly
poucoPrescribed
mais for Children
ANALGESIC
BOSNIAN Ne boli Boli samo malo
RECOMMENDED Boli malo
ADVANTAGES Boli jos̆ vis̆e
DISADVANTAGES Boli puno
HOW SUPPLIEDBoli najvis̆e
vis̆e
DOSAGE-ORAL
VIETNAMESE KhôngROUTE
dau Ho̊i dau Dau ho̊n Dau nhiêu Dau thât Dau qúa
chút ho̊n nhiêu dô

CHINESE†

GREEK ∆εν Πoνaϊ Πoνaϊ Λιγo Πoνaϊ Λιιγo Πoνaϊ Πoνaϊ Πιo Πoνaϊ
Πιo Πoλν Πoλν Πoλν Πaρa Πoλν

ROMANIAN No doare Doare puţin Doare un Doare Doare Doare cel

pic mai mult şi mai mult foarte tare mai mult

The Handbook of Pediatric Dentistry 171

 ADDITIONAL READINGS AND WEBSITES

172 The Handbook of Pediatric Dentistry

 Chapter 15: HOSPITAL DENTISTRY
AND GENERAL ANESTHESIA

A. Charles Post and Erwin G. Turner

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/P_HospitalStaff.pdf
http://www.aapd.org/media/Policies_Guidelines/P_HospitalizationInfants.pdf
http://www.aapd.org/media/Policies_Guidelines/P_3rdPartySedGA.pdf
http://www.aapd.org/media/Policies_Guidelines/G_Sedation.pdf
http://www.aapd.org/media/Policies_Guidelines/G_AnesthesiaPersonnel.pdf

174 HOSPITAL OPPORTUNITIES

174 REQUIREMENTS FOR MEDICAL STAFF MEMBERSHIP
AND HOSPITAL PRIVILEGES
174 GOALS OF GENERAL ANESTHESIA (T)
176 PRE-OPERATIVE WORKUP AND CONSULTATION (T)
177 PRE-ANESTHETIC PHYSICAL EXAMINATION
178 PRE-SURGERY DOCUMENTATION
179 PRE-SURGERY ANESTHESIA ASSESSMENT
179 OPERATING ROOM PROTOCOL
181 POST-SURGICAL ORDERS
182 OPERATIVE REPORT
182 DISCHARGE CRITERIA (T)
183 POST-OPERATIVE INSTRUCTIONS (RX)
184 POST-SURGICAL COMPLICATIONS
184 ADDITIONAL READINGS AND WEBSITES
 HOSPITAL OPPORTUNITIES

REQUIREMENTS FOR MEDICAL STAFF MEMBERSHIP

AND HOSPITAL PRIVILEGES (CREDENTIALING)

Medical-Dental Staff Member Responsibilities

GOALS OF GENERAL ANESTHESIA

Indications

Contraindications

174 The Handbook of Pediatric Dentistry

 EXAMPLE OF DOCUMENTATION FOR GENEREAL
ANESTHESIA CARE
Appendix

Criteria for Dental Therapy Under General Anesthesia

Total points needed to justify treatment under general anesthesia=22.

Age of client at time of examination Points

Less than four years of age 8
Four and five years of age 6
Six and seven years of age 4
Eight years of age and older 2

Treatment Requirements (Carious and/or Abscessed Teeth) Points

1-2 teeth or one sextant 3
3-4 teeth or 2-3 sextants 6
5-8 teeth or 4 sextants 9
9 or more teeth or 5-6 sextants 12

Behavior of Client** Points

Definitely negative–unable to complete exam, client unable to cooperate due to lack of physical or emotional 10
maturity, and/or disability
Somewhat negative–defiant; reluctant to accept treatment; disobeys instruction; reaches to grab or deflect 4
operator’s hand, refusal to take radiographs
Other behaviors such as moderate levels of fear, nervousness, and cautious acceptance of treatment should be 0
considered as normal reponses and are not indications for treatment under general anesthesia
** Requires that narrative fully describing circumstances be present in the client’s chart

Additional Factors** Points

Presence of oral/perioral pathology (other than caries), anomaly, or trauma requiring surgical intervention** 15
Failed conscious sedation** 15
Medically compromising of handicapping condition** 15
** Requires that narrative fully describing circumstances be present in the client’s chart

I understand and agree with the dentist’s assessment of my child’s behavior.

PARENT/GUARDIAN SIGNATURE: ____________________________________________________DATE: ________________

Clients in need of general anesthesia who do not meet the 22-point threshold, by report, will require prior authorization.

To proceed with the dental care and general anesthesia, this form, the appropriate narrative, and all supporting
documentation, as detailed in Attachment 1, must be included in the client’s chart. The client’s chart must be
available for review by representatives of TMHP and/or HHSC.

PERFORMING DENTIST’S SIGNATURE: ________________________________________________________

DATE: ________________License No. ____________________________

Effective Date_01012009/Revised Date_12172008

–1

The Handbook of Pediatric Dentistry 175

 PREOPERATIVE WORKUP AND CONSULTATION
Pre operating room workup

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–
–

Parent/guardian Consultation

NPO Guidelines
6-36 Months >36 Months

176 The Handbook of Pediatric Dentistry

 Informed Consent

Child’s Psychological Management:

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PRE-ANESTHETIC PHYSICAL EXAMINATION

Vital Signs

Measurements

General Observations

Organ Systems

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The Handbook of Pediatric Dentistry 177

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Summary List of Problems/Tentative Diagnosis

PRE-SURGERY DOCUMENTATION
Dates Required

Surgery Location

Type of Admission

Patient Information

178 The Handbook of Pediatric Dentistry

 Completed Forms

Additional Forms (as applicable)

PRE-SURGERY ANESTHESIA ASSESSMENT

OPERATING ROOM PROTOCOL (DAY

OF SURGERY)
Pre-Op Evaluation

Medical Record

–
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Dental Personnel

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The Handbook of Pediatric Dentistry 179

 Universal Protocol

– (SIGN-IN) -

– (TIME-OUT) -

– (SIGN-OUT) -

Anesthesia Protocol

Dental Preoperative Protocol

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180 The Handbook of Pediatric Dentistry

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Dental Operative Procedure

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The Handbook of Pediatric Dentistry 181

 OPERATIVE REPORT
Required within 24 hours

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DISCHARGE CRITERIA

182 The Handbook of Pediatric Dentistry

 MODIFIED ALDRETE POST ANESTHESIA RECOVERY SCORE
>9 Required for Discharge
Activity – Voluntarily or on Command

Respiration

Circulation

Oxygenation

Consciousness

POSTOPERATIVE INSTRUCTIONS (ORAL AND

WRITTEN)

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The Handbook of Pediatric Dentistry 183

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ADDITIONAL READINGS AND WEBSITES

184 The Handbook of Pediatric Dentistry

Chapter 16: MEDICAL EMERGENCIES

Steven Ganzberg and J.C. Shirley

186 PREPARATION FOR EMERGENCIES (T)

188 PREVENTION OF EMERGENCIES
188 MANAGEMENT OF EMERGENCIES-GENERAL
PRINCIPLES
189 COMMON MEDICAL EMERGENCIES
194 SUMMARY (T)
196 ADDITIONAL READINGS AND WEBSITES
 PREPARATION FOR EMERGENCIES

α β1 β2

β2

»
–

IM
–

–
MI

186 The Handbook of Pediatric Dentistry

 –

↓ 2
↑ 2

–
MI

Pharmacology How Brand

Drug Indication Website
Supplied Name

http://www.epipen.
α β1 β2 com

http://www.
β2
proventil.com
www.ventolin.com

http://www.
novonordiskcare.
com/glucagen-
emergency-kit/

http://www.diastat.
com

http://www.
benadryl.com

http://www.
ncbi.nlm.nih.gov/
pubmedhealth/
PMH0000802
http://www.
ncbi.nlm.nih.gov/
pubmedhealth/
PMH0000080

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The Handbook of Pediatric Dentistry 187

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PREVENTION OF EMERGENCIES

MANAGEMENT OF EMERGENCIES —
GENERAL PRINCIPLES

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188 The Handbook of Pediatric Dentistry

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COMMON MEDICAL EMERGENCIES

Syncope

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The Handbook of Pediatric Dentistry 189

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Hyperventilation syndrome

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Acute asthma

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190 The Handbook of Pediatric Dentistry

 Chest pain/Angina pectoris/MI

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The Handbook of Pediatric Dentistry 191

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192 The Handbook of Pediatric Dentistry

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The Handbook of Pediatric Dentistry 193

 SUMMARY

AMERIC AN AC ADEMY OF PEDIATRIC DENTISTRY

Cardiopulmonary Resuscitation
Summary of Key BLS Components for Adults, Children and Infants

Reprinted with permission 2010 American Heart Association Guidelines

For CPR and ECC
Part 4: CPR Overview
Circulation. 2010;122[suppl 3]:S676-S684]
©2010 American Heart Association, Inc.

RESOURCE SEC TION 347

194 The Handbook of Pediatric Dentistry

 Figure 3. Pediatric BLS Algorithm.

The Handbook of Pediatric Dentistry 195

 ADDITIONAL READINGS AND WEBSITES

196 The Handbook of Pediatric Dentistry

 Chapter 17: ALLERGIC
AND IMMUNE DISORDERS

Georgiana M. Sanders and Ruwaida GH. Tootla

198 ANAPHYLAXIS
199 ALLERGIC RHINITIS
200 ATOPIC DERMATITIS
201 URTICARIA AND ANGIOEDEMA
202 HEREDITARY ANGIOEDEMA
203 FOOD ALLERGY
204 LATEX ALLERGY (T)
207 ASTHMA
212 RHEUMATOLOGIC DISEASES
JUVENILE ARTHRITIS
VASCULITIDES IN CHILDREN
SYSTEMIC LUPUS ERYTHEMATOSUS
217 CONGENITAL AND ACQUIRED
IMMUNODEFICIENCIES (T)
224 ADDITIONAL READINGS AND WEBSITES
 ANAPHYLAXIS
DEFINITION
Anaphylaxis is an overwhelming, immediate systemic reaction due to an IgE
Mediated release of mediators from tissue mast cells and peripheral blood
basophils. This reaction occurs rapidly and can be fatal. Anaphylactoid reactions
are similar in appearance but are not mediated by IgE.
EPIDEMIOLOGY/CAUSATION
Anaphylaxis is responsible for 500-1000 fatalities yearly. The most common causes of
anaphylaxis are:

COURSE OF DISEASE
Mild reactions may occur with only:

DIAGNOSIS

vasovagal reaction

anxiety
cardiac events

if in doubt, treat for anaphylaxis to prevent serious consequences

It is important to identify previously known allergies before treating a

TREATMENT
This is a medical emergency, prompt treatment is mandatory.
If the patient has a few hives, mild nausea:

198 The Handbook of Pediatric Dentistry

 needed

as the epinephrine

hypotension, loss of consciousness:

ALLERGIC RHINITIS
CLINICAL PRESENTATION

ETIOLOGY AND PATHOGENESIS

DIAGNOSIS

MANAGEMENT: 3 steps

cromolyn sodium and decongestants

pharmacotherapy

treatment is targeted to these coexisting medical conditions.

The Handbook of Pediatric Dentistry 199

 COMPLICATIONS

DENTAL CONSIDERATIONS

the patient to an allergist for testing

ATOPIC DERMATITIS (atopic eczema)

CLINICAL PRESENTATION

scratching

and hyperpigmentation without erythema

popliteal fossa
ETIOLOGY

rhinitis
DIAGNOSIS

pruritis

young age of onset

elevated serum IgE and total eosinophil counts, especially in children with
asthma

neoplastic conditions

metabolic defects

200 The Handbook of Pediatric Dentistry

 MANAGEMENT

preparations are to be used with caution in children

DENTAL CONSIDERATIONS

the child’s physician.

URTICARIA & ANGIOEDEMA

CLINICAL PRESENTATION

layers that blanch with pressure

swelling is deeper
primarily affects the face, extremities, genitalia with occasional tongue
enlargement or laryngeal edema

foods, medications, insect stings, infection

DIAGNOSIS

etiology
thyroid disease
lymphoproliferative neoplasms
connective tissue disorders
MANANGEMENT

The Handbook of Pediatric Dentistry 201

 DENTAL CONSIDERATIONS

HEREDITARY ANGIOEDEMA
ETIOLOGY

Esterase inhibitor
CLINICAL PRESENTATION

trauma
medical or dental procedures
emotional stress
menstruation
infections
oral contraceptives
other medications

characteristically:
non-pitting
tensely swollen
painful
not erythematous, warm or pruritic

lips
eyelids
tongue
extremities
genitalia

in:

typically, swelling does not extend beyond the larynx

MANAGEMENT

procedures, although it will probably be replaced by the newer therapies, where

available

202 The Handbook of Pediatric Dentistry

 rapid administration of anabolic steroids is no longer the preferred therapy
tracheotomy is potentially lifesaving

hereditary angioedema
a routinely well managed patient is not a contraindication for dental treatment
some perioral swelling may occur following dental procedures, this should not
discourage the dentist from treating these patients

FOOD ALLERGY
CLINICAL PRESENTATION

nausea
vomiting
diarrhea
abdominal pain

tongue, lip and perioral edema

pruritis of the palate or lips

rhinorrhea
nasal pruritis
bronchoconstriction
laryngeal edema
ETIOLOGY AND PATHOGENESIS

Most children outgrow their allergies during the elementary school years, although the
following allergies often persist into adulthood:

The Handbook of Pediatric Dentistry 203

 Atopic dermatitis can be exacerbated by food allergies

food allergies
DIAGNOSIS

diagnosis of a suspected IgE-mediated food allergy

MANAGEMENT

use
DENTAL CONSIDERATIONS

food allergens and even to contact from someone who has recently consumed
these products, an important consideration for maintaining patient safety in the

LATEX ALLERGY (LA)

ETIOLOGY AND PATHOGENESIS

Hevea brasiliensis

CLINICAL PRESENTATION

causative factors:
maceration and abrasion from constant glove wearing
repeated hand washing and incomplete hand drying

exposure to powders added to gloves

204 The Handbook of Pediatric Dentistry

 delayed hypersensitivity reaction caused primarily by accelerators, promoters,
and antioxidants added to natural rubber latex during harvesting, processing and
manufacturing
t-cell mediated immune response

with the offending products

swelling, redness and itching

DIAGNOSIS OF LATEX ALLERGY

in vivo latex challenge

AT-RISK POPULATIONS

contact of latex products occur with mucosal surfaces occurs:

spinal cord trauma

urogenital and gastroinstestinal malformations
neurogenic bladder
hydrocephalus internus with ventriculo-peritoneal shunts

rhinitis

urticaria
angioedema
coughing
shortness of breath

individuals predisposed to multiple allergies such as a family history of hay fever,

developing severe latex allergy compared to the general population

The Handbook of Pediatric Dentistry 205

 some of the latex proteins share a similar epitope to that of proteins found in

concurrent latex allergy

PREVENTIVE STRATEGIES

use reduced-protein, powder-free latex gloves or, preferably, non-latex varieties

use non-latex dental products

problems
perform adequate hand hygiene after using latex gloves

may resolve dermatitis

suspected latex allergy- avoid direct latex contact until evaluated by a physician
evidence of immediate hypersensitivity reaction to latex
avoid all contact with all latex products
avoid areas with high latex aeroallergen content
follow physician’s instructions for dealing with allergic reactions

patients allergic to latex must be treated in a latex free environment:

use latex-free gloves, other latex-free devices, latex free procedure tray

TREATMENT OF AN ACUTE ALLERGIC REACTION TO LATEX

allergic reaction:

apply high-potency topical corticosteroids

administer topical intranasal corticosteroids and oral antihistamine

206 The Handbook of Pediatric Dentistry

 LATEX DENTAL PRODUCTS AND THEIR LATEX-FREE
ALTERNATIVES

Alternative
Gloves
elastomer, styrene-based copolymer, methyl
methacrylate, polyurethane

metal base

Adhesive tape
Anesthetic carpule Glass ampules

Impression materials containing latex

Gutta percha
percha through apex
Molt mouth prop with silastic wrap

Elastic ligature thread Elastomeric thread

Astroscope

Glass syringes

ASTHMA
DEFINITION

cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes,

neutrophils, and epithelial cells

the early morning

obstruction that is often reversible either spontaneously or with treatment

EPIDEMIOLOGY
Asthma is the most common chronic medical condition of childhood

years old
There is a difference in prevalence based on race, socioeconomic status and
location

The Handbook of Pediatric Dentistry 207

 CAUSATION
Asthma symptoms are caused by airways narrowing secondary to:

Triggers for this process include:

COURSE OF DISEASE AND PROGNOSIS

symptoms before they are 5 years old

with
old

concurrent atopic dermatitis or a parent with asthma

two or more of:
allergic rhinitis
peripheral blood eosinophilia

COMPLICATIONS

secondary to an exposure including

reaction

if present, must supplement for extensive surgical procedures

208 The Handbook of Pediatric Dentistry

 DIAGNOSIS

history
physical examination

chest tightness
dry cough

dyspnea
anxiety
DIFFERENTIAL DIAGNOSIS

MEDICAL TREATMENT

all patients with chronic asthma should be on a controlling medication

other controllers include

theophyllines
cromologs
long-acting beta agonists only if added to inhaled corticosteroid when control

all patients with asthma should have a reliever available and should bring that to
the dental appointment

The Handbook of Pediatric Dentistry 209

 MANAGING AN ACUTE ASTHMA ATTACK: This is a medical emergency.

puff, wait one minute and repeat, holding the breath 10 seconds after each puff

monitor vital signs

agonists

DENTAL CONSIDERATIONS

DELIVERING SAFE DENTAL CARE

is not
periodic intervals. Any indication of the following is suggestive of poor asthma
control and necessitates referral to the child’s physician:

concurrent upper respiratory illness causing asthma symptoms

pulmonary status
level of asthma control, i.e.

frequency of changes in medication protocol

210 precipitants The Handbook of Pediatric Dentistry
 treatment
major dental treatment

systemic glucocorticoids were used in the last month

uncontrolled exercise-induced bronchospasm

poor pulmonary function
SEDATION ISSUES

barbiturates

both drugs stimulate histamine release leading to bronchospasm

effective in mild to moderate asthmatics

avoid prolonged periods of use, it is delivered anhydrous, can be irritating to the
airway drying the bronchial secretions

Anecdotal triggers, associated allergies and cautions:

tooth enamel dust

methyl methacrylate

cotton rolls

the rare possibility of:

palpitations
increased blood pressure
arrhythmias

drugs, use acetaminophen in these cases

should not receive erythromycin- raises theophylline blood levels to a toxic range
theophylline is rarely used today

The Handbook of Pediatric Dentistry 211

 RHEUMATOLOGIC DISEASES
JUVENILE ARTHRITIS
DEFINITION/EPIDEMIOLOGY/CLASSIFICATION

separate categories which are further divided into subgroups to better explore etiologies,

hepatomegaly, splenomegaly, serositis

positive family history of anterior uveitis with pain, a spondyloarthropathy, or

anterior uveitis associated with pain, redness, or photophobia

seldom occurs before second decade of life

two groups
arthritis and psoriasis

PROGNOSIS AND COMPLICATIONS

within the subgroups

leading to destructive arthritis with associated complications

most cases benign

early onset has guarded prognosis with expected persistence of disease

adolescents probably represent early-onset adult-type disease
complications

uveitis

212 The Handbook of Pediatric Dentistry

 rate

spondylitis, possibly severe with disability, more guarded prognosis if associated

MEDICAL TREATMENT

therapy for the arthritides

second-line therapies are immunosuppresive, including but not limited to:

intra-articular corticosteroids are also used

DENTAL CONSIDERATIONS

important consideration when positioning the patient in the dental chair

chair for prolonged periods of time

with diminished mouth opening

decreased mandibular growth leading to orthodontic problems

the articular cartilage has no blood supply and little reparative capacity, so once

which may require surgical intervention to regain lost function

interactions should be monitored

involved

SURGICAL CONSIDERATION

The Handbook of Pediatric Dentistry 213

 suppression

VASCULITIDES IN CHILDREN
WEGENER GRANULOMATOSIS

discharge
subglottic stenosis

pulmonary hemorrhage

BECHET DISEASE

per year

purpura

small vessel vasculitis common

less commonly involves cardiac, gastrointestinal and pulmonary systems

TREATMENT OF THE VASCULITIDES IN CHILDREN

chronic phase often related to complications of therapy

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
DEFINITION/EPIDEMIOLOGY

214 The Handbook of Pediatric Dentistry

 CLINICAL PRESENTATION

symptoms. Most common presentation in childhood:

fever
malaise
failure to thrive

fever
nephritis
abdominal complaints
DIAGNOSIS

both children and adults

> >

photosensitivity

thrombocytopenia

antinuclear antibody
COURSE OF DISEASE/PROGNOSIS/COMPLICATIONS

poor compliance with treatment regimens

neurologic complications

renal disease, particularly diffuse proliferative glomerulonephritis

socioeconomic status
disease activity
central nervous system involvement
renal involvement

malignancy secondary to therapeutic regimens

cardiovascular disease

The Handbook of Pediatric Dentistry 215

 MEDICAL TREATMENT

hydroxychloroquine in mild

methotrexate
mycophenolate mofetil

DENTAL CONSIDERATIONS

patients may have treatment induced depletion of antibodies

procedures or severely anxious patients

before prescribing any additional medication

clinical manifestation

216 The Handbook of Pediatric Dentistry

CONGENITAL AND ACQUIRED
IMMUNODEFICIENCIES (see table)

and usually lead to increased susceptibility to infection at birth or in early

childhood, but may not be evident until later

malnutrition, malignancy, or immunosuppressive medications

of an involvement of a number of organ systems

complement, phagocytes
ORAL MANIFESTATIONS

B CELL DEFICIENCIES (see table for detail)

DENTAL MANAGEMENT

any invasive dental procedure

organisms resulting from its chronic use in these patients

The Handbook of Pediatric Dentistry 217

218
IMMUNE DEFICIENCIES
MEDICAL
EPIDEMIOLOGY/ LABORATORY & DENTAL
DEFECT CHARACTERISTICS DIAGNOSIS COMPLICATIONS MANAGEMENT

Agammaglobulinemia - males only, diagnosed normal T-cells, recurrent bacterial intravenous

absent or very infections, odontogenic
infections predispose to
septicemia, recurrent oral
reduced serum aphthae
immunoglobulins
- Autosomal recessive mutation in one of
several genes
recurrent severe gamma globulin
no IgG responsive sinopulmonary infections, replacement, as
recessive antibodies, IgM hepatitis, lymphoid appropriate for other
or autosomal hyperplasia, automimmune complications
recessive, defect disease, oral candidiasis and
in class switching, ulceration are common,

both sexes, usually selective IgA increased susceptibility to prophylactic

Immunoglobulin differentiation bacterial infection or no antibiotics, severe
clinical concern
no production of may require Ig
selected isotype. replacement

most common

The Handbook of Pediatric Dentistry

 autosomal decreased T-cells, mycobacterial, viral T-cell function
and fungal infections, improves with age,
spontaneous, births. hypocalcemic tetany often normal by 5
normal or secondary to absent years old, severe cases
pharyngeal pouch decreased serum corrected by fetal
maldevelopment immunoglobulins patients have palatal thymic transplantation
with thymic
palate, velopharyngeal bone marrow
agenesis leading incompetence, and transplantation

The Handbook of Pediatric Dentistry

maturation, conotruncal heart
deletion in disease, prominent nose
chromosome
mental retardation, oral
cardiofacial candidiasis, herpes infection
are common, enamel
hypoplasia may occur
cases

219
220
MEDICAL
EPIDEMIOLOGY/ LABORATORY & DENTAL
DEFECT CHARACTERISTICS DIAGNOSIS COMPLICATIONS MANAGEMENT

mutation in gene recurrent, severe bacterial

on x-chromosome infection, diarrhea, cell transplantation
encoding the cells, normal or failure to thrive, usually curative, haplo-
common gamma begins in infancy, includes identical
chain shared by reduced serum candidiasis, fatal viral transplantation less
immunoglobulins infections after attenuated successful

to transfusion, fatal if not

treated, oral candidiasis,
herpes, recurrent tongue
and buccal mucosa
ulceration, severe

gingival stomatitis.
Adenosine lymphopenia, clinical picture similar to
cell transplantion
buildup of toxic autosomal recessive progressive decrease tonsils and lymph tissue,
purine metabolites
in lymphocytes reduced serum may present later, into
immunoglobulins adulthood, lymphomas
complicate partial and

The Handbook of Pediatric Dentistry

 Ataxia-Telangiectasia defective ATM both sexes, autosomal elevated alpha- progressive cerebellar antibiotics, gamma
recessive, usually diagnosed fetoprotein in ataxia, oculocutaneous globulin infusions
on chromosome telangiectasia, diabetes
1:100,000 live births, immunoglobulin mellitus, increased
buildup of somatic malignancies, progressive
mutations are carriers production of pulmonary disease
antibody to secondary to infections,
bacteria containing poor prognosis
polysaccharides in
cell wall

The Handbook of Pediatric Dentistry

variable
gene located at recessive, rare autosomal, picture from thrombocytopenia, marrow transplant
average age at diagnosis, thrombocytopenia recurrent infections preferred, if not
to effect on all blood available: splenectomy,
intravenous
automimmune disorders immunoglobulins,
antibiotics

221
222
MEDICAL
EPIDEMIOLOGY/ LABORATORY & DENTAL
DEFECT CHARACTERISTICS DIAGNOSIS COMPLICATIONS MANAGEMENT

loss or inactivation males > females, often decreased recurrent intracellular fungal subcutaneous
Granulomatous of one of and bacterial infections
components of oxidase activity gamma, antibiotic and
determined by antifungal prophylaxis
oral candidiasis, gingivitis,
recessive test, cytochrome and oral ulcers similar to
reduction that of aphthous ulcers in
assay, oxidative presentation and course but
affects the attached gingivae,
discoid lesions, very rarely
intraoral granulomas
rare, autosomal recessive, delayed separation of the severe disease: bone
both severe and moderate umbilical cord, recurrent marrow or stem cell
common chain of phenotypes bacterial infections, transplantation, mild-
moderate disease:
but extremely rare] family leads to antibiotic therapy
defect in migration periodontitis, absent pus
and chemotaxis formation, impaired wound

defect in adhesion gingivitis, rapidly progressing

and transmigration
through endothelial oral ulcers that heal very
cells slowly with scarring, severe
phenoype often fatal,
moderate often survive into
adulthood

The Handbook of Pediatric Dentistry

 mutation in childhood form autosomal neutrophil counts spectrum of disease antibacterial mouth
neutrophil elastase dominant, diagnosed from asymptomatic to rinses and good
gene causing plaque control,
defect in stem cell age and mucus membranes, antibiotic therapy,
regulation approximately symptoms often decrease

neutropenia lasting neutrophil count

periodontitis, may escape
the primary dentition,

The Handbook of Pediatric Dentistry

edematous with gingival
recession, ulceration and
desquamation
defective gene mild neutropenia partial albinism, aggressive
pyogenic infections, partial with giant photophobia, nystagmus, antibacterial therapy,
with defective oculocutaneous albinism, cytoplasmic recurrent pyogenic splenectomy, bone
transport of neurologic abnormalitis granules, decreased infections, malignant marrow transplant,
bacteria to chemotaxis, lymphomas, accompanied evaluate blood
lysosome and by neutropenia, anemia, parameters prior to
thrombocytopenia, severe any dental procedures,
phagocytosed consult with the
bacteria rapidly progressing early patient’s physician
childhood periodontitis
with premature exfoliation
of teeth

223
 ADDITIONAL READINGS AND WEBSITES
1.

224 The Handbook of Pediatric Dentistry

 Chapter 18: CHILDHOOD CANCER

Marcio daFonseca

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_Chemo.pdf

226 INCIDENCE AND OUTCOMES

227 ORAL COMPLICATIONS OF CHEMOTHERAPY
AND RADIOTHERAPY
228 ORAL AND DENTAL MANAGEMENT
231 ADDITIONAL READINGS AND WEBSITES
 INCIDENCE AND OUTCOMES
Childhood cancer is rare, representing < 1% of all new cancer dx

Most common cancers in children 0-19 years of age

– highest incidence rate found among children 1-4 years

–

–
–

–
10 years
–

–
second most common malignancy and the most common solid tumors of
childhood*
highest incidence found among children 1-4 years
–

Other childhood cancers

– third most common form of childhood cancer

–

–
adolescence
–

– arise from the neural crest tissue

–

* Most statistics do not include low grade CNS tumors. If they are accounted for, CNS cancers then become
the most common form of childhood malignancy and the leading cause of cancer-related morbidity and
mortality.
226 The Handbook of Pediatric Dentistry
 –

most commonly in the adrenal gland, usually appears as a swelling in the

–
–

–
–

–
years of age
–

–
–

–
sarcoma
–

14 years of age

cancers, particularly female sex, childhood cancer at a younger age, childhood

ORAL COMPLICATIONS OF CHEMOTHERAPY AND

RADIOTHERAPY

well as treatment outcomes

The Handbook of Pediatric Dentistry 227

 height

ORAL AND DENTAL MANAGEMENT

Before the initiation of cancer therapy and transplantation conditioning
–
local irritants
–
treatment protocol, hematological status, presence of a central line, and, in

PREVENTIVE STRATEGIES

– once daily if patient is properly trained

– chlorhexidine only if the patient has poor oral hygiene or periodontal disease

–
content of pediatric oral medications

–
cancer therapy

* complication of radiotherapy only

228 The Handbook of Pediatric Dentistry

 HEMATOLOGICAL PARAMETERS

– 3

– 3

– 3

– 3

DENTAL PROCEDURES

central line is present unless the patient is immunosuppressed

– infections, extractions, scaling, and sources of tissue irritation

– carious teeth, root canal therapy and replacement of faulty restorations

ENDODONTICS

–
–
status, extraction is indicated

extract
–

ORTHODONTICS

– good oral hygiene →

– poor oral hygiene →

–
hygiene
PERIODONTICS

–
indicated

The Handbook of Pediatric Dentistry 229

 ORAL SURGERY

–
–
–
osteoradionecrosis
–

teeth
–

During cancer therapy and early phases of transplantation

PREVENTIVE STRATEGIES

DENTAL PROCEDURES

an odontogenic infection
ORAL TISSUES

–
hematological status
–
http://www.ngc.gov/content.aspx?id=12094

–
–
–

–
–

– rule out caries and odontogenic infection

–

After cancer therapy and transplantation

PREVENTIVE STRATEGIES

DENTAL PROCEDURES

230 The Handbook of Pediatric Dentistry

 ORAL SURGERY

ORTHODONTICS

ORAL TISSUES

–
–
– close monitoring of soft tissues
–
–
–

ADDITIONAL READINGS AND WEBSITES

The Handbook of Pediatric Dentistry 231

 Chapter 19: CARDIOVASCULAR
DISEASES

Amr M. Moursi and Amy L. Truesdale

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_AntibioticProphylaxis.pdf

233 CONGENITAL HEART DISEASE

233 RHEUMATIC FEVER
234 RHEUMATIC HEART DISEASE
234 HEART MURMUR
235 CARDIAC ARRHYTHMIAS
236 HYPERTENSIVE HEART DISEASE
237 CONGESTIVE HEART FAILURE
238 INFECTIVE ENDOCARDITIS
238 CARDIAC CONDITIONS ASSOCIATED WITH
INFECTIVE ENDOCARDITIS
239 DENTAL PROCEDURES REQUIRING
PROPHYLAXIS AND INFECTIVE ENDOCARDITIS
REGIMENS (T)
240 ADDITIONAL READINGS AND WEBSITES
CONGENITAL HEART DISEASE
INITIAL LEFT TO RIGHT SHUNTING OF BLOOD
Examples:

OBSTRUCTION OF BLOOD FLOW

CARDIAC DEFECTS

SYMPTOMS

COMPLICATIONS

MEDICAL MANAGEMENT

DENTAL EVALUATION/MANAGEMENT

RHEUMATIC FEVER

streptococcal

The Handbook of Pediatric Dentistry 233

 PREVALENCE

SYMPTOMS

COMPLICATIONS

MEDICAL MANAGEMENT

RHEUMATIC HEART DISEASE

INCIDENCE

SYMPTOMS

COMPLICATIONS

MEDICAL MANAGEMENT

DENTAL MANAGEMENT

HEART MURMURS

234 The Handbook of Pediatric Dentistry

CARDIAC ARRHYTHMIAS

SIGNS

SYMPTOMS

COMPLICATIONS

MEDICAL EVALUATION

RISK CLASSIFICATION

MEDICAL MANAGEMENT

DENTAL MANAGEMENT

The Handbook of Pediatric Dentistry 235

 ORAL COMPLICATIONS

HYPERTENSIVE HEART DISEASE

Age S/D

SYMPTOMS

COMPLICATIONS

MEDICAL MANAGEMENT

DENTAL EVALUATION/MANAGEMENT

236 The Handbook of Pediatric Dentistry

 ORAL COMPLICATIONS

CONGESTIVE HEART FAILURE

ETIOLOGY

SYMPTOMS

COMPLICATIONS

MEDICAL MANAGEMENT

DENTAL MANAGEMENT

ORAL COMPLICATIONS

The Handbook of Pediatric Dentistry 237

 INFECTIVE ENDOCARDITIS

Staphylococcus aureus

Streptococcus viridans

SYMPTOMS

COMPLICATIONS

MEDICAL MANAGEMENT

DENTAL MANAGEMENT

CARDIAC CONDITIONS ASSOCIATED WITH

INFECTIVE ENDOCARDITIS

Prevention of infective endocarditis- American Heart Association guidelines of April 2007 (Wilson, et al.,
2007

238 The Handbook of Pediatric Dentistry

 NOT

DENTAL PROCEDURES REQUIRING PROPYLAXIS AND

INFECTIVE ENDOCARDITIS REGIMENS

Situation Agent, Route and Time Regimen

*IM – intramuscular; IV – intravenous

The Handbook of Pediatric Dentistry 239

 ADDITIONAL READINGS AND WEBSITES

Pediatrics

240 The Handbook of Pediatric Dentistry

Chapter 20: ENDOCRINE DISORDERS

Paul Walker and Homa Amini

242 PANCREAS
244 THYROID GLAND
247 ADRENAL GLAND
251 PARATHYROID GLAND
252 PITUITARY GLAND
255 ADDITIONAL READINGS AND WEBSITES
 Endocrine describes the actions of hormones secreted into the bloodstream. Hormones

PANCREAS

DIABETES MELLITUS

–
–
–

–
–
–

»
»

–
–
–
–
–

242 The Handbook of Pediatric Dentistry

 –
–

DENTAL CONSIDERATIONS

–
–
–
–
–

–
–

The Handbook of Pediatric Dentistry 243

 –

»
»

THYROID GLAND

HYPOTHYROIDISM

–
–

–
–
–
–
–

244 The Handbook of Pediatric Dentistry

 Clinical Signs and Symptoms:
Hair loss
Hoarseness

–
disease
–

–
–
–
–
–
–

–
–
–
–
–
HYPERTHYROIDISM

The Handbook of Pediatric Dentistry 245

 –

–
–
–
–
–
–

–
–

–
–
–
–
is common
–
at births
–

246 The Handbook of Pediatric Dentistry

 Table I: Dental management of the hyperthyroid patient
Disease status Clinical action

disease

controlled
Avoid use of epinephrine or pressor amines

Well controlled

ADRENAL GLAND

The Handbook of Pediatric Dentistry 247

 ADRENAL INSUFFICIENCY (AI)

hormones
–

»
»
»
»
»
»

»
»
»
»
»
»
–

»
»

»
»
»

children
– adrenal crisis

hormone

248 The Handbook of Pediatric Dentistry

 medical treatment
»

»
»

»
»

»
»
»
DENTAL CONSIDERATIONS

–
–

Stress dosing of hydrocortisone for pediatric patients

The Handbook of Pediatric Dentistry 249

 Common steroid agents and their relative potency
Glucocorticoid
Mineralocorticoid
Duration Equivalent Potency (anti-
Agent potency (salt
of action dose (mg)
retaining effect)
effect)

HYPERADRENALISM (Cushing syndrome)

–
–
Symptoms

Headache
Thirst

–
–
–
–

250 The Handbook of Pediatric Dentistry

 –
–

–
–

PARATHYROID GLAND

–
–
– actions

–
–
–
–
–
–

canal

radiation

The Handbook of Pediatric Dentistry 251

 –

–
–
–

»
»
» enamel attrition
»
»
»
»
»

–
–

PITUITARY GLAND

Hormones produced by the anterior

pituitary and their regulatory actions

hormones

Lactation

252 The Handbook of Pediatric Dentistry

 Hormones stored in the posterior pituitary
(produced in hypothalamus) and their actions

HYPOPITUITARISM

–
–
–
–
–

–
–
–

–
–
–
–

–
–
–
–
–
–
–
–
– cessation of menses

–
–

–
–
–

The Handbook of Pediatric Dentistry 253

 HYPERPITUITARISM

Signs and Symptoms

feet

Headaches

–
–
–
–

254 The Handbook of Pediatric Dentistry

 – macroglossia
– temporomandibular arthritis
– macrodontia
– hypercementosis
– radiodense cortical plate

DENTAL CONSIDERATIONS

ADDITIONAL READINGS AND WEBSITES

1.

2.

The Handbook of Pediatric Dentistry 255

 Chapter 21: HEMATOLOGIC
DISORDERS

Brian Sanders and Barbara Sheller

257 ANEMIAS
257 BLEEDING DISORDERS
258 ORAL EVALUATION
259 MANAGEMENT
259 ADDITIONAL READINGS AND WEBSITES
ANEMIAS

DENTAL CONSIDERATIONS
Low-risk patient

High-risk patient

BLEEDING DISORDERS

The Handbook of Pediatric Dentistry 257

 »
»
»

»
»
»
»
»

»
»
»
»
»
»

»
»
»
»

»
»
»

»
»
»

ORAL EVALUATION

258 The Handbook of Pediatric Dentistry

MANAGEMENT

ADDITIONAL READINGS AND WEBSITES

The Handbook of Pediatric Dentistry 259

 Chapter 22: INFECTIOUS DISEASES

Jeffrey Karp and Robert Berkowitz

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_AntibioticTherapy.pdf

261 PREVENTION (T)

261 BACTERIAL INFECTIONS
264 VIRAL INFECTIONS (T)
270 FUNGAL INFECTIONS
271 PARASITE INFECTIONS
271 ADDITIONAL READINGS AND WEBSITES
PREVENTION
Recommended Immunization Schedule for Persons Aged 0 Through 6 Years‰6OJUFE
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UIPTF
XIP
GBMM
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Vaccine Age Birth month months months months months months months months years years
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#1 HepB HepB HepB

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DTaP DTaP DTaP see DTaP DTaP BHFT
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DIJMESFO
Haemophilus influenzae
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*OBDUJWBUFE
1PMJPWJSVT6 IPV IPV IPV IPV

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*OáVFO[B7 Influenza (Yearly) SFDPNNFOEFE

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7BSJDFMMB9 Varicella see footnote 9 Varicella

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"10 HepA (2 doses) HepA Series

.FOJOHPDPDDBM11 MCV4

This schedule includes recommendations in effect as of December 21, 2010. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and
feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Considerations should include provider assessment, patient preference,
Recommended Immunization
and the potential for adverse events. Providers should consultSchedule for
the relevant Advisory Persons
Committee Aged
on Immunization 7 Through
Practices 18 recommendations:
statement for detailed Years‰6OJUFE
4UBUFT
t

http://www.cdc.gov/vaccines/
pubs/acip-list.htm. Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS) at http://www.vaers.hhs.gov or by
telephone, 800-822-7967.For those who fall behind or start late, see the schedule below and the catch-up schedule

1. Hepatitis B vaccine (HepB). (Minimum age: birth) r
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desired.
r
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r
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a booster dose at age 16 through 18 years. with incomplete vaccination, follow the catch-up schedule.
r
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r
Administer 2 doses at least 8 weeks apart to children aged 2 through 10 years 8. Inactivated poliovirus vaccine (IPV).
with persistent complement component deficiency and anatomic or functional r
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asplenia, and 1 dose every 5 years thereafter. birthday and at least 6 months following the previous dose.
r
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r
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countries with highly endemic or epidemic disease and during outbreaks caused r
The minimum interval between the 2 doses of MMR is 4 weeks.
by a vaccine serogroup. 10. Varicella vaccine.
r
Administer MCV4 to children at continued risk for meningococcal disease who r
For persons aged 7 through 18 years without evidence of immunity (see
were previously vaccinated with MCV4 or meningococcal polysaccharide vac- MMWR 2007;56[No. RR-4]), administer 2 doses if not previously vaccinated
cine after 3 years (if first dose administered at age 2 through 6 years) or after 5 or the second dose if only 1 dose has been administered.
years (if first dose administered at age 7 years or older). r
For persons aged 7 through 12 years, the recommended minimum interval
4. Influenza vaccine (seasonal). between doses is 3 months. However, if the second dose was administered
The Handbook of Pediatric Dentistry
r
For healthy nonpregnant persons aged 7 through 18 years (i.e., those who
do not have underlying medical conditions that predispose them to influenza
at least 4 weeks after the first dose, it can be accepted as valid.
r
For persons aged 13 years and older, the minimum interval between doses 261
complications), either LAIV or TIV may be used. is 4 weeks.
r
Administer 2 doses (separated by at least 4 weeks) to children aged 6 months
through 8 years who are receiving seasonal influenza vaccine for the first
 Bacterial Pharyngitis

Gonococcal Stomatitis

Neisseria gonorrhoeae

262 The Handbook of Pediatric Dentistry

 Syphilis

Treponema pallidum,

Tuberculosis

Mycobacterium tuberculosis

–
–
–

The Handbook of Pediatric Dentistry 263

 VIRAL INFECTIONS
Hand-Foot-Mouth Disease

Herpangina

Acute Nasopharyngitis

264 The Handbook of Pediatric Dentistry

 Acute Herpetic Gingivostomatitis

The Handbook of Pediatric Dentistry 265

 Recurrent Herpes Simplex Virus

Chickenpox

266 The Handbook of Pediatric Dentistry

 Infectious Mononucleosis

Hepatitis B

The Handbook of Pediatric Dentistry 267

 Condyloma Acuminatum

HAART
Age Criteria
Recommendation

268 The Handbook of Pediatric Dentistry

 HAART
Age Criteria
Recommendation

Treatment for oral lesions in pediatric HIV patients:

The Handbook of Pediatric Dentistry 269

 FUNGAL INFECTIONS
Candidiasis
Candida albicans

270 The Handbook of Pediatric Dentistry

PARASITE INFECTIONS
Lice

ADDITIONAL READINGS AND WEBSITES

The Handbook of Pediatric Dentistry 271

272 The Handbook of Pediatric Dentistry
 Chapter 23: NEPHROLOGY

Marcio daFonseca and Ashok Kumar

274 DEFINITIONS
274 MEDICAL TREATMENT OF END STAGE RENAL
DISEASE (ESRD) (T)
275 PROPHYLACTIC ANTIBIOTICS PRIOR TO
DENTAL TREATMENT
276 ORAL AND DENTAL MANAGEMENT
279 ADDITIONAL READINGS AND WEBSITES
 DEFINITIONS
RENAL INSUFFICIENCY
A patient’s renal reserve can compensate to a point at which < 50% of renal function
remains. Once the damage is past the point of compensation, its function is initially
mildly to moderately diminished, resulting in an impaired ability to maintain the internal
environment.
RENAL FAILURE

valid parameter of renal function. The kidney function deteriorates to the point of chronic
abnormalities in the internal environment thus normal homeostasis cannot be maintained
leading, for example, to metabolic acidosis and hypocalcemia.
END-STAGE RENAL DISEASE (ESRD)
It is a chronic, irreversible, progressive disease characterized by the destruction of 50% to
75% of the nephrons which leads to the retention and accumulation of excretory products

and chronic glomerulonephritis.

MEDICAL TREATMENT OF ESRD

or the clinical status of the child requires a more aggressive mode of treatment either in the
form of dialysis or renal transplant. The most common cause of death in renal disease is
cardiovascular complication, followed by infection and malignancy.
DIALYSIS

of the kidneys but it does not correct the endocrine abnormalities associated with renal
failure.
There are two

An elastic catheter is surgically placed in the peritoneal cavity with intermittent

infusion and drainage of a sterile electrolyte solution in a plastic bag that cleans

the patient greater freedom than hemodialysis.

to access the patient’s bloodstream through direct anastomosis of native vessels or

274 The Handbook of Pediatric Dentistry

 RENAL TRANSPLANTATION
Although patient survival is approximately equal in patients receiving a transplant and
those treated by dialysis, there are major differences when considering quality of life issues

possible

ORAL MANIFESTATIONS OF ESRD / RENAL TRANSPLANTATION

Malodor

Xerostomia Increased risk for development of

squamous cell carcinoma, Kaposi sarcoma

Uremic stomatitis
Oral hairy leukoplakia
Malocclusion
Increased risk of jaw fracture
Mucosal pallor Low caries

Tooth mobility

Increased deposition of calculus Abnormal bone healing after extractions

Bone demineralization Oral secondary infections due
immunosuppression
Oral metastases from renal tumors
Loss of lamina dura

Lytic areas of bone

Widening of the periodontal ligament

PROPHYLACTIC ANTIBIOTICS PRIOR TO DENTAL

TREATMENT
There is no convincing evidence that microorganisms associated with dental procedures

grafts, at any time after implantation. Infections in these devices are often associated with
their surgical implantation or resulting from wound or other active infections. Thus, the
not recommend antibiotic prophylaxis after device
placement for patients who undergo dental procedures, except in cases of incision and
drainage of an oral infection or immunosuppression.
The Handbook of Pediatric Dentistry 275
 ORAL AND DENTAL MANAGEMENT
DURING RENAL THERAPY AND BEFORE TRANSPLANTATION

– identify, stabilize or eliminate existing and potential sources of oral infection and
local irritants
– oral hygiene instruction
– radiographic exam to identify pathoses and bone changes caused by renal
osteodystrophy in the jaws
– patient and caretaker education

surgeries, congestive heart failure

anemia

» level of immunocompromise
history of prolonged bleeding
– cause and severity of the renal disease
–
physician’s name and phone number

medications
» dosage, schedule, route, allergies
dialysis type and regimen
» access type
» use of anticoagulants
transplant

– past care, symptomatic teeth, trauma hx, etc

– toothbrushing

hematological status
–
Once daily
– oral rinses
chlorhexidine rinses if the patient has poor oral hygiene or periodontal
disease
– diet

content of pediatric oral medications

–

xerostomia

276 The Handbook of Pediatric Dentistry

 – xerostomia

– education of patients and caretakers

discuss the importance of optimal oral care, the oral effects of drugs, the risk
of invasive dental procedures in patients using bisphosphonates

– consult with physician before any invasive dental care is provided

– deferral of treatment may be needed until disease is adequately controlled
– in most cases when the disease is well controlled, there are no contraindications
for routine dental care

– bleeding tendency
platelets
»
prolonged bleeding
» < 75,000 mm
coagulation tests
»

anemia status
» hematocrit, hemoglobin
adrenal status
» consult physician about supplemental corticosteroids
antibiotic prophylaxis
» consult physician

– endodontics
primary teeth
»

status, extraction is indicated

permanent teeth
»

»
hematological status is stable
– orthodontics

»
»
full mouth appliances
»
overgrowth or in cases of poor oral hygiene
»
patients with bone involvement
– periodontics
gingival hypertrophy
» consider gingivectomy in moderate and severe cases

The Handbook of Pediatric Dentistry 277

 – oral surgery
orofacial infections
» treat aggressively and consider hospitalization for severe infections and
major dental procedures
» spontaneous dental abscesses may occur due to the formation of
globular dentin with clefts and defects in the dentinal tubules in vitamin

extractions
»
» no clear recommendations for use of antibiotics following extractions
»

restorable teeth
» individual assessment of impacted teeth
bleeding disorder
» pay meticulous attention to the surgical technique
»

» currently there are no recommendations for its prevention and treatment

following extractions, excisional biopsies, and preparation and
placement of dental implants in patients who have used or are using
bisphosphonates
drug prescription
» discuss dose adjustment with physician
»

» penicillins can be used in normal doses, except for high potassium

due to its high potassium levels

» aminoglycosides, tetracyclines and cephalosporins should be avoided due
to nephrotoxicity
» most narcotics can be used safely, except for meperidine which forms a
metabolite that may accumulate and cause seizures
» local anesthetics are safe and well tolerated
–
dialysis patients
» dental care should be scheduled soon after dialysis
»
the volume used is small and the risk of excessive bleeding is
minimal
» avoid the day before dialysis because of increasing uremia and
consequent failing platelet function
»
shunt
» avoid dental care during episodes of peritoneal infection
transplant patients
»
not feasible, prioritize procedures and place temporary restorations until
the patient is stable
–
infections, extractions, scaling, and sources of tissue irritation

278 The Handbook of Pediatric Dentistry

 carious teeth, root canal therapy and replacement of faulty restorations
the risk of pulpal infection and pain determines which carious lesions should

AFTER TRANSPLANTATION

– patients may become high caries risk after the transplant

– defer all elective procedures during immunosuppression periods

– consult physician in cases of dental emergencies
–
– discuss need for antibiotic prophylaxis and supplemental steroids with physician
– odontogenic and other oral infections should be treated aggressively during
immunosuppression

– increased risk of oral malignancy, probably related to immunosuppression

– watch for secondary infections
cultures and biopsies when appropriate
nystatin prophylaxis is ineffective in immunocompromised patients

–
– consider risk of gingival overgrowth and patient’s oral hygiene status

– assess need for gingivectomy, consider patient’s compliance and oral hygiene
status

ADDITIONAL READINGS AND WEBSITES

The Handbook of Pediatric Dentistry 279

 Chapter 24: PATIENTS WITH SPECIAL
HEALTH CARE NEEDS

Lewis Kay, Constance Killian and Rochelle Lindemeyer

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/G_SHCN.pdf

281 AUTISM AND AUTISM SPECTRUM DISORDER

283 ATTENTION DEFICIT HYPERACTIVITY DISORDER
285 INTELLECTUAL DISABILITY/DEVELOPMENTAL
DELAY
286 SEIZURE DISORDER
288 MITACHONDRIAL DISORDERS
290 NEURAL TUBE DEFECTS
291 HYDROCEPHALUS
292 CEREBRAL PALSY
294 MUSCULAR DYSTROPHIES (MD)
294 DEAFNESS
295 ADDITIONAL READINGS AND WEBSITES
AUTISM AND AUTISM SPECTRUM DISORDER
INCIDENCE

SPECTRUM

–
–
–
–
–

–
–
–

–
–

EARLY SIGNS

DENTAL CONSIDERATIONS

The Handbook of Pediatric Dentistry 281

 Medications for Autism

Symptoms Targeted
Hyperactivity, impulsivity, Stimulants
inattention

Atypical antipsychotics

Alpha-2 adrenergic agonists

Selective norepinephrine reuptake inhibitor

Anti-convulsant mood stabilizers

Disruptive behaviors, Atypical antipsychotics

aggression, tantrums, and
self injury
Repetitive behaviors, Selective serotonin reuptake inhibitors “SSRI”
sterotypies, and rigidity

Serotonin-selective tricyclic antidepressant

Atypical antipsychotics
Anti-convulsant

Selective serotonin reuptake inhibitors “SSRI”

Mood dysregulation Mood stabilizers / antimanic

Atypical antipsychotics
SSRI
Depression SSRI
Seratonin norepinephrine reuptake inhibitors “SNRI”

Used with permission from Dr. Barbara Sheller-Children’s Hospital, Seattle, WA

DENTAL TREATMENT

282 The Handbook of Pediatric Dentistry

 SPECIFICS IN DENTAL TREATMENT

ATTENTION DEFICIT HYPERACTIVITY

DISORDER (ADHD)

POSSIBLE ETIOLOGIES

CORE SYMPTOMS

SUBTYPES

CHILD MAY DISPLAY FUNCTIONAL PROBLEMS

COMMONLY OCCURS WITH OTHER DISORDERS

The Handbook of Pediatric Dentistry 283

 DIAGNOSIS

MEDICAL MANAGEMENT

»
»
»
»
»
»
»
»
»
»

»
–

»
»
»
»
»

DENTAL CONSIDERATIONS

284 The Handbook of Pediatric Dentistry

INTELLECTUAL DISABILITY/DEVELOPMENTAL DELAY

ASSUMPTIONS

ETIOLOGY–MANIFESTATION OF A GROUP OF DISORDERS OF CNS

FUNCTION

–
–

–
–
–
–

–
–
–
–
–

The Handbook of Pediatric Dentistry 285

 MAJOR ORAL FINDINGS

–
–
–
–
–
–
–
DENTAL CONSIDERATIONS

SEIZURE DISORDERS

286 The Handbook of Pediatric Dentistry

 CLASSIFICATION

–
–
–

–
–
–
–
–
–
–

»
»

»
»

SEIZURE HISTORY FOR DENTAL PATIENTS

MEDICAL MANAGEMENT OF SEIZURE DISORDERS

ORAL EVALUATION AND MANAGEMENT

The Handbook of Pediatric Dentistry 287

 MANAGEMENT OF A SEIZURE

–
–

–
–
–
–
–

MITOCHONDRIAL DISORDERS

–
–
–
–
–
–
–
–
–
–
–

288 The Handbook of Pediatric Dentistry

 MITOCHONDRIAL MYOPATHY, ENCEPHALOPATHY, LACTIC ACIDOSIS
AND STROKE-LIKE EPISODES (MELAS)

–
–

GENETICS

TESTING

TREATMENT

CLINICAL MANIFESTATIONS

COMMON ORAL FINDINGS

DENTAL MANAGEMENT

–
–
–

The Handbook of Pediatric Dentistry 289

 NEURAL TUBE DEFECTS

INCIDENCE

CAUSES

TYPES

–
–
–

–
–
–
–

–
–

»
»
»

»
»
»
»

»
»
»

290 The Handbook of Pediatric Dentistry

 MEDICAL MANAGEMENT OF NEURAL TUBE DEFECTS

–
–

–
–
DENTAL CONSIDERATIONS

HYDROCEPHALUS

–
–

–
–
–
–
–

–
–
–
–
–
–

The Handbook of Pediatric Dentistry 291

 –
–

DENTAL CONSIDERATIONS

CEREBRAL PALSY

CLASSIFICATION

MEDICATIONS

292 The Handbook of Pediatric Dentistry

 CLINICAL MANIFESTATIONS

COMMON DENTAL/ORAL FINDINGS

DENTAL CONSIDERATIONS

–
–
–
–
–

FEATURES OF CEREBRAL PALSY THAT CAN COMPLICATE SEDATIONS:

The Handbook of Pediatric Dentistry 293

 MUSCULAR DYSTROPHIES (MD)

CLASSIFICATION

–
–
–
–
–
–

COMMON DENTAL/ORAL FINDINGS

DENTAL CONSIDERATIONS

DEAFNESS
ETIOLOGY

294 The Handbook of Pediatric Dentistry

Note–American Sign Language (ASL) is NOT English in sign language BUT it is a language unto itself as
is French or Italian or any other language for the people served. In essence it is the language of deaf people.
DENTAL CONSIDERATION

ADDITIONAL READINGS AND WEBSITES

The Handbook of Pediatric Dentistry 295

296 The Handbook of Pediatric Dentistry
 Chapter 25: NEW MORBIDITIES

Homa Amini, Kevin L. Boyd, Karen M. Crews, Neva Penton

Eklund, Paul E. Kittle, Jr., Howard L. Needleman, Megann
Smiley and Sarat Thikkurissy

AAPD ORAL HEALTH POLICIES AND CLINICAL GUIDELINES:

http://www.aapd.org/media/Policies_Guidelines/RS_BMICharts.pdf
www.aapd/org.media/Policies_Guidelines/G_childabuse.pdf
www.aapd.org/media/Policies_Guidelines/D_DentalNeglect.pdf
http://www.aapd.org/media/Policies_Guidelines/P_ChildIDPrograms.pdf
http://www.aapd.org/media/Policies_Guidelines/P_TobaccoUse.pdf
http://www.aapd.org/medial/Policies_Guidelines/G_PerinatalOralHealthCare.pdf

298 PREGNANCY (T)

303 EATING DISORDERS
305 OVERWEIGHT AND OBESITY
308 CHILD ABUSE AND NEGLECT (T)
311 SUBSTANCE ABUSE
316 TOBACCO USE AMONG YOUTH (T)
321 ADDITIONAL READINGS AND WEBSITES
 PREGNANCY
Statistics and Terminology

Diagnosis of Pregnancy

Cardiac and respiratory changes associated with pregnancy

↑

Pregnancy Related Morbidities

Oral Conditions – Pregnancy Oral Findings – Preterm birth

298 The Handbook of Pediatric Dentistry

 Role of Oral Health Professional

–
–

–
–

–
–

–
–
–

The Handbook of Pediatric Dentistry 299

 –

300 The Handbook of Pediatric Dentistry

 Pharmacological Considerations
for Pregnant and Breastfeeding Women
Drug FDA Teratogenic Quality of the Restrictions/Special
Risk Evidence Considerations
ANALGESICS
C

The Handbook of Pediatric Dentistry 301

Drug FDA Teratogenic Quality of the Restrictions/Special
Risk Evidence Considerations
ANTIBIOTICS

ANESTHETICS
Fair
MISCELLANEOUS
Fair

302 The Handbook of Pediatric Dentistry

 FDA Category Ratings

EATING DISORDERS (ED)

ATTITUDES, BEHAVIORS AND CHANGE

ANOREXIA NERVOSA (AN)

The Handbook of Pediatric Dentistry 303

 –

BULIMIA NERVOSA (BN)

304 The Handbook of Pediatric Dentistry

 –

OVERWEIGHT AND OBESITY

–
–
–
2
–

The Handbook of Pediatric Dentistry 305

 »
http://www.cdc.gov/obesity/childhood/data.html
Epidemiology

–
–

–
–
–
–

http://www.healthychildren.org/english/
health-issues/conditions/obesity
–

Associated Morbidities

–
–
–

306 The Handbook of Pediatric Dentistry

 –
–

–
–

–
–

–
–

–
–
–

–
Treatments

–
–

The Handbook of Pediatric Dentistry 307

 –

Associations with Dental Caries

Dental Management Concerns

CHILD ABUSE AND NEGLECT

308 The Handbook of Pediatric Dentistry

 support, love and affection, education, safety, and medical care and dental care

conditions if left untreated can lead to pain, infection, and loss of function

Epidemiology

Causation

Prognosis

Complications

Diagnosis

GENERAL CHARACTERISTICS OF ABUSED AND ABUSER

Abuser Pro le Abused Pro le

The Handbook of Pediatric Dentistry 309

 EVENT-RELATED CHARACTERISTICS

Exam, History and Documentation

Differential Diagnosis

Medical Treatment

Must report if suspicious

Dental/Oral Findings

Dental Management

310 The Handbook of Pediatric Dentistry

Missing and Exploited Children

Amber Alert
Amber Hagerman

Code Adam
Adam Walsh

www.aapd.org/mediaPolicies_
Guidelines/P_ChildIDPrograms.pdf

SUBSTANCE ABUSE

Diagnostic and Statistical Manual of Mental Disorders

The Handbook of Pediatric Dentistry 311

 –

Signs of Substance Abuse in Children and Adolescents

Behavioral Changes

Emotional Changes

312 The Handbook of Pediatric Dentistry

 Mental Changes

Physical Changes

Talking to Children and Adolescents about Substance Abuse

COMMONLY ABUSED SUBSTANCES

TOBACCO
Alternative Tobacco Products

–
http://www.tobaccofreekids.org

–
–
–

The Handbook of Pediatric Dentistry 313

 –
–

http://www.nicotinewater.com)

–
–

– http://www.cdc.gov/tobaccco

–
http://www.cdc.gov/tobaccco

–
–
–

314 The Handbook of Pediatric Dentistry

 –

–
http://healthresources.caremark.com/topic/herbalcig

–
http://www.cancer.org

–
–
http://www.nih.gov
Drugs

–
–
–

–
–
–

The Handbook of Pediatric Dentistry 315

 TOBACCO USE AMONG YOUTH

Prevalence Among Youth

Spit (Smokeless) Tobacco

316 The Handbook of Pediatric Dentistry

 Oral (moist) snuff

Loose leaf chewing tobacco

Plug chewing tobacco

Nasal snuff
–

Additional Considerations when Discussing Tobacco Use and Cessation with

Youth

Environmental Tobacco Smoke (ETS)

The Handbook of Pediatric Dentistry 317

 5A’s Brief Intervention to Treat Tobacco Dependence

5 A’s Model
Passive Exposure Initiation
Anticipate

Ask

Advise

Assess
Assist
Arrange

Anticipate
–
–
–
–
Ask

Ask

Advise

Assess
Assist

Arrange
Arrange

318 The Handbook of Pediatric Dentistry

 Risk Factors for Tobacco Use
Anticipate

Ask

Advise

–
–
–
Assess
Assist

Arrange

Medications for Tobacco Cessation

Medication 1st
Proper Use Advantages Disadvantages
Line Options
Nicotine
Transdermal
Patch (Nicoderm,
Nicotrol,
Habitrol)

Nicotine
Polacrilex (‘gum’)

(Nicorette)

The Handbook of Pediatric Dentistry 319

 Nicotine Inhaler

(Nicotrol)

Nicotine
Nasal Spray

(Nicotrol NS)

Nicotine
Lozenge

(Commit)

Bupropion SR

(Zyban)

320 The Handbook of Pediatric Dentistry

 Varenicline
(Chantix)

2nd Line Options

Nortriptyline

Clonidine

oral

ADDITIONAL READINGS AND WEBSITES

Pregnancy

The Handbook of Pediatric Dentistry 321

 Obesity

Child Abuse and Neglect (CAN)

322 The Handbook of Pediatric Dentistry

 Substance Abuse
Diagnostic and Statistical Manual of Mental
Disorders

Tobacco

The Handbook of Pediatric Dentistry 323

 Chapter 26: RESOURCE SECTION

325 GROWTH CHARTS

329 BODY MASS INDEX (BMI) CHARTS
331 DIETARY GUIDELINES FOR AMERICA – 2010
333 RECOMMENDED FOOD INTAKE PATTERNS
335 SPEECH AND LANGUAGE MILESTONES
336 ASSESSMENT OF ACUTE TRAUMATIC INJURIES
338 PREPARING FOR YOUR CHILD’S SEDATION VISIT
340 SEDATION RECORD
342 POST-OPERATIVE INSTRUCTIONS FOR
EXTRACTIONS/ORAL SURGERY
344 COMMON LABORATORY VALUES
345 COMMON PEDIATRIC MEDICATIONS
347 MANAGEMENT OF MEDICAL EMERGENCIES
GROWTH CHARTS

The Handbook of Pediatric Dentistry 325

326 The Handbook of Pediatric Dentistry
The Handbook of Pediatric Dentistry 327
328 The Handbook of Pediatric Dentistry
BODY MASS INDEX (BMI) CHARTS

The Handbook of Pediatric Dentistry 329

330 The Handbook of Pediatric Dentistry
DIETARY GUIDELINES FOR AMERICA-2010
http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/ExecSumm.pdf
Eating and physical activity patterns that are focused on consuming fewer calories,
making informed food choices, and being physically active can help people attain and
maintain a healthy weight, reduce their risk of chronic disease, and promote overall

recommendations that accommodate the food preferences, cultural traditions, and customs
of the many and diverse groups who live in the United States.
Dietary Guidelines recommendations traditionally have been intended for healthy
Americans ages 2 years and older. However, Dietary Guidelines for Americans, 2010 was
released at a time of rising concern about the health of the American popula¬tion. Poor
diet and physical inactivity are the most important factors contributing to an epidemic of
overweight and obesity affecting men, women, and children in all segments of our society.
Even in the absence of overweight, poor diet and physical inactiv¬ity are associated with
major causes of morbidity and mortality in the United States. Therefore, the Dietary
Guidelines for Americans, 2010 is intended for Americans ages 2 years and older, including
those at increased risk of chronic disease.
The following are the Dietary Guidelines for Americans, 2010 Key Recommendations.
These Key Recommendations are the most important in terms of their implications for

Guidelines recommendations in their entirety as part of an overall healthy eating pattern.

Balancing calories to manage weight

physical activity behaviors.

or obese, this will mean consuming fewer calories from foods and beverages.

adolescence, adulthood, pregnancy and breastfeeding, and older age.

Foods and nutrients to increase

pattern while staying within their calorie needs.

and beans and peas.

eggs, beans and peas, soy products, and unsalted nuts and seeds.

place of some meat and poultry.

The Handbook of Pediatric Dentistry 331

 which are nutrients of concern in American diets. These foods include vegetables,
fruits, whole grains, and milk and milk products.

Americans to help consumers make better food choices.

consumer behavior alone.

332 The Handbook of Pediatric Dentistry

RECOMMENDED FOOD INTAKE PATTERNS

The Handbook of Pediatric Dentistry 333

334 The Handbook of Pediatric Dentistry
SPEECH AND LANGUAGE MILESTONES

What should my child be able to do?

Hearing and Understanding Talking

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The Handbook of Pediatric Dentistry 335

 ASSESSMENT OF ACUTE TRAUMATIC INJURIES

336 The Handbook of Pediatric Dentistry

The Handbook of Pediatric Dentistry 337
 AMERIC AN AC ADEMY OF PEDIATRIC DENTISTRY

Preparing for Your Child’s Sedation Visit

PREPARING FOR YOUR CHILD’S SEDATION VISIT

Patient: ______________________________ Sedation appointment: ___________ at _______AM/PM

We have recommended sedation for your child’s safety and comfort during dental procedures. Sedation can help increase
cooperation and reduce anxiety and/or discomfort associated with dental treatment. Various medications can be used to sedate
a child; medicines will be selected based upon your child’s overall health, level of anxiety, and dental treatment recommenda-
tions. Once the medications have been administered, it may take up to an hour before your child shows signs of sedation
and is ready for dental treatment. Most children become relaxed and/or drowsy and may drift into a light sleep from which
they can be aroused easily. Unlike general anesthesia, sedation is not intended to make a patient unconscious or unresponsive.
Some children may not experience relaxation but an opposite reaction such as agitation or crying. These also are common
responses to the medicines and may prevent us from completing the dental procedures. In any case, our staff will observe
your child’s response to the medications and provide assistance as needed.
You, as parent/legal guardian, play a key role in your child’s dental care. Children often perceive a parent’s anxiety which
makes them more fearful. They tolerate procedures best when their parents understand what to expect and prepare them for
the experience. If you have any questions about the sedation process, please ask. As you become more confident, so will your
child. For your child’s safety, you must follow the instructions below.

Prior to your child’s sedation appointment:

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stomach contents into the lungs, a potentially life-threatening problem. We will not proceed with the sedation if you
do not comply with the following requirements.

TYPE OF FOOD / LIQUID MINIMUM FASTING PERIOD

Clear liquids (water, fruit juices without pulp, carbonated beverages and clear tea) 2 hours before sedation
Breast milk 4 hours before sedation
Formula, non-human milk, and light meal (toast and clear liquid) 6 hours before sedation
Fried or fatty foods or meat 8 hours before sedation

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preferable to have 2 adults accompany the patient home. On the way home, one individual should be able to observe
the child’s breathing without any distractions, especially if the patient falls asleep while in the car or safety seat.

RESOURCE SEC TION 335

338 The Handbook of Pediatric Dentistry

REFERENCE MANUAL V 33 / NO 6 11 / 12

During the sedation appointment:

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head until the snoring disappears and your child breathes normally. If breathing becomes abnormal or you are unable to
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336 RESOURCE SEC TION

The Handbook of Pediatric Dentistry 339

 AMERIC AN AC ADEMY OF PEDIATRIC DENTISTRY

SEDATION RECORD
Sedation Record
Patient Selection Criteria Date: ________________________
Patient: _____________________________ M F Age: _____yr____mo Weight: _______kg Physician: ___________________
Indication for sedation: Fearful/anxious patient for whom basic behavior guidance techniques have not been successful
Patient unable to cooperate due to lack of psychological or emotional maturity and/or mental, physical, or medical disability
To protect patient’s developing psyche
To reduce patient’s medical risk
Medical history/review of systems (ROS) NONE YES* Describe positive findings: ____________ Airway Assessment NONE YES*
Allergies &/or previous adverse drug reactions _________________________________ Obesity
Current medications (including OTC) _________________________________ Limited neck mobility
Relevant diseases, physical/neurologic impairment _________________________________ Micro/retrognathia
Previous sedation/general anesthetics _________________________________ Macroglossia
Snoring, obstructive sleep apnea, mouth breathing _________________________________ Tonsillar obstruction (___%)
Other significant findings (eg, family history) _________________________________ Limited oral opening
ASA classification: I II I I I* IV* E * Medical consultation indicated? NO YES Date requested: __________________
Comments: _____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Is this patient a candidate for in-office sedation? YES NO Doctor’s signature: ______________________________ Date: ___________________

Plan Name/relation to patient Initials Date By

Informed consent obtained from ________________________________________ ________ _____________ _________________________
Pre-op instructions reviewed with ________________________________________ ________ _____________ _________________________
Post-op precautions reviewed with ________________________________________ ________ _____________ _________________________

Assessment on Day of Sedation Date: ___________________

Accompanied by: ____________________________________ Relationship(s) to patient: ________________________

Medical Hx & ROS update NO YES NPO status Airway assessment NO YES Checklist

Change in medical hx/ROS Clear liquids ____hrs Upper airway clear Appropriate transportation home
Change in medications Milk, other liquids, Lungs clear Monitors functioning
Recent respiratory illness &/or foods ____hrs Tonsillar obstruction (___%) Emergency kit, suction, & O2
Weight: _______kg Medications ____hrs available

Vital signs (If unable to obtain, check and document reason: ______________________________________________________ )
Blood pressure: ______/______ mmHg Resp: ______/min Pulse: ______/min Temp: ______oF SpO2:______%
Comments: _____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Presedation cooperation level: Unable/unwilling to cooperate Rarely follows requests Cooperates with prompting Cooperates freely
Behavioral interaction: Definitively shy and withdrawn Somewhat shy Approachable
Guardian was provided an opportunity to ask questions, appeared to understand, and reaffirmed consent for sedation? YES NO

Drug Dosage Calculations

Sedatives
Agent ________________________________ Route ________ ________mg/kg X _______kg = ________mg ÷ _________mg/mL = _________mL
Agent ________________________________ Route ________ ________mg/kg X _______kg = ________mg ÷ _________mg/mL = _________mL
Agent ________________________________ Route ________ ________mg/kg X _______kg = ________mg ÷ _________mg/mL = _________mL
Emergency reversal agents
For narcotic: NALOXONE IV, IM, or subQ Dose: 0.1 mg/kg X _____ kg = ______mg (Maximum dose: 2 mg; may repeat)
For benzodiazepine: FLUMAZENIL IV (preferred), IM Dose: 0.01 mg/kg X _____ kg = ______mg (Maximum dose: 0.2 mg; may repeat up to 4 times)
Local anesthetics (maximum dosage based on weight)
Lidocaine 2% (34 mg/ 1.7 mL cartridge) 4.4 mg/kg X _______kg = ________mg (not to exceed 300 mg total dose)
Articaine 4% (68 mg/ 1.7 mL cartridge) 7 mg/kg X _______kg = ________mg (not to exceed 500 mg total dose)
Mepivacaine 3% (51 mg/ 1.7 mL cartridge) 4.4 mg/kg X _______kg = ________mg (not to exceed 300 mg total dose)
Prilocaine 4% (68 mg/ 1.7 mL cartridge) 6 mg/kg X _______kg = ________mg (not to exceed 400 mg total dose)
Bupivacaine 0.5% (8.5 mg/ 1.7 mL cartridge) 1.3 mg/kg X _______kg = ________mg (not to exceed 90 mg total dose)

RESOURCE SEC TION 337

340 The Handbook of Pediatric Dentistry

REFERENCE MANUAL V 33 / NO 6 11 / 12

Intraoperative Management and Post-Operative Monitoring EMS telephone number: ________________________

Monitors: Observation Pulse oximeter Precordial/pretracheal stethoscope Blood pressure cuff Capnograph EKG Thermometer
Protective stabilization/devices: Papoose Head positioner Manual hold Neck/shoulder roll Mouth prop Rubber dam _______

TIME Baseline : : : : : : : : : : : : : : : :
Sedatives1
N2O/O2 (%)
Local 2 (mg)

O2 sat
Pulse
BP
Resp
CO2

Procedure3
Comments4
Sedation level*
Behavior †

1. Agent ________________________________ Route _________ Dose _________ Time _________ Administered by ______________________
Agent ________________________________ Route _________ Dose _________ Time _________ Administered by ______________________
Agent ________________________________ Route _________ Dose _________ Time _________ Administered by ______________________
2. Local anesthetic agent ___________________________________________________
3. Record dental procedure start and completion times, transfer to recovery area, etc.
4. Enter letter on chart and corresponding comments (eg, complications/side effects, airway intervention, reversal agent, analgesic) below:
A. _______________________________________________________ B. _______________________________________________________
C. _______________________________________________________ D. _______________________________________________________
Sedation level * Behavior/ responsiveness to treatment †
None (typical response/ cooperation for this patient) Excellent: quiet and cooperative
Mild (anxiolysis) Good: mild objections &/or whimpering but treatment not interrupted
Moderate (purposeful response to verbal commands ± light tactile sensation) Fair: crying with minimal disruption to treatment
Deep (purposeful response after repeated verbal or painful stimulation Poor: struggling that interfered with operative procedures
General Anesthesia (not arousable) Prohibitive: active resistance and crying; treatment cannot be rendered
Overall effectiveness: Ineffective Effective Very effective Overly sedated
Additional comments/treatment accomplished: _________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________

Discharge
Criteria for discharge Discharge vital signs
Cardiovascular function is satisfactory and stable. Protective reflexes are intact. Pulse: ______/ min
Airway patency is satisfactory and stable. Patient can talk (return to presedation level). SpO2: ______%
Patient is easily arousable. Patient can sit up unaided (return to presedation level). BP: ______/______ mmHg
Responsiveness is at or very near presedation level State of hydration is adequate. Resp: ______/ min
(especially if very young or special needs child incapable of the usually expected responses). Temp: ______oF

Discharge process
Post-operative instructions reviewed with ________________________________________________ by ________________________________________
Transportation Airway protection/observation Activity Diet Nausea/vomiting Fever Rx Anesthetized tissues
Dental treatment rendered Pain Bleeding ______________________________ Emergency contact
Next appointment on: _______________________________________________________________ for _______________________________________

I have received and understand these discharge instructions. The patient is discharged into my care at _________ AM PM
Signature: ______________________________________ Relationship: ________________________ After hours number: _________________________

Operator Chairside Monitoring

Signature: _____________________________ Assistant: _______________________ Personnel signature: ________________________

Post-op call
Date: ______________ Time: _________ By: _________ Spoke to: __________________________ Comments: _______________________________
______________________________________________________________________________________________________________________________
338 RESOURCE SEC TION

The Handbook of Pediatric Dentistry 341

 Post-operative Instructions for Extractions/
POST-OPERATIVE INSTRUCTIONS FOR
Oral Surgery
EXTRACTIONS/ORAL SURGERY
Patient: __________________________________________________________ Date: ________________________________

Your child had the following procedure performed today: Extraction Exposure of unerupted tooth
Frenectomy Biopsy Gingivectomy Gingival graft Other: __________________________________
This will require special care and attention over the next few days. Please follow the instructions checked below. Contact us with questions or
if unusual symptoms develop.
Numbness: The mouth will be numb approximately 2-4 hours. Watch to see that your child does not bite, scratch, or injure the
cheek, lips, or tongue during this time.
Bleeding: Bleeding was controlled before we discharged your child, but some occasional oozing (pink or blood-tinged saliva)
may occur. Hold gauze with firm pressure against the surgical site until oozing has stopped. You may need to change the gauze
or repeat this step. If bleeding continues for more than 2 hours, contact us.
Surgical Site Care: Today, do not disturb the surgical site. Do not stretch the lips or cheeks to look at the area. Do not rinse
vigorously, use mouthwash, or probe the area with fingers or other objects. Beginning tomorrow, you may rinse with warm salt
water (½ teaspoon salt with 1 cup water) after meals.
Sutures: Sutures (stitches) were placed to help control bleeding and promote healing. These sutures
will dissolve and do not need to be removed OR will be removed at your follow-up visit.
If the stitches come out during the first 48 hours, call our office.
Daily Activities: Today, avoid physical exercise and exertion. Return to normal activities as tolerated. Smoking is never good for
one’s health and may delay healing following oral surgery.
Diet: After all bleeding has stopped, the patient may drink cool non-carbonated liquids but should NOT use a straw. Encourage
fluids to help avoid dehydration. Cold soft foods (eg, ice cream, gelatin, Instant Breakfast®, pudding, yogurt) are ideal the first day.
By the second day, consistency of foods can progress as tolerated. Until healing is more established, avoid foods such as nuts, sun-
flower seeds, and popcorn that may get lodged in the surgical areas.
Oral Hygiene: Keeping the mouth clean is essential. Today, teeth may be brushed and flossed gently, but avoid stimulating the
surgical site. Soreness and swelling may not permit vigorous brushing of all areas, but please make every effort to clean the teeth
within the bounds of comfort.
Pain: Because some discomfort is expected, you may give your child acetaminophen (Tylenol®) or ibuprofen (Motrin®,
Advil®) before the numbness wears off. Do NOT give aspirin to your child. Follow the instructions on the bottle for dosing
based upon your child’s age/weight. If pain is not relieved by one of these medications, a prescription may be needed. Take pre-
scription pain medication with a small amount of food to avoid nausea.
Prescription: You were prescribed pain medicine antibiotics oral rinse other ______________________
Directions: _____________________________________________________________________________________________
______________________________________________________________________________________________________
Other: __________________________________________________________________________________________________
______________________________________________________________________________________________________
Watch for:
Swelling: Slight swelling and inflammation may occur for the next 2 days. If swelling occurs, ice packs may be used for the
first 24 hours (10 minutes on then 10 minutes off ) to decrease swelling and/or bruising. If swelling persists after 24 hours,
warm/moist compresses (10 minutes on then 10 minutes off) may help. If swelling occurs after 48 hours, call our office.
Fever: A slight fever (temperature to 100.5°F) is not uncommon the first 48 hours after surgery. If a higher fever develops or
the fever persists, call our office.
Dry Socket: Premature dissolving or loss of a blood clot following removal of a permanent tooth may result in a “dry socket”. This
typically occurs on the 3rd to 5th day after the extraction, with a persistent throbbing pain in the jaw. Call our office if this occurs.
Follow-up: Schedule your child’s next visit for ____________________________________ in _________ days/weeks/months.

Contact Numbers: Office: _______________________________________ After Hours: _________________________________

RESOURCE SEC TION 339

342 The Handbook of Pediatric Dentistry

Common Laboratory Values
COMMON LABORATORY VALUES
CBC
Test Normal value Function Significance
Hemoglobin 12-18 g/100 mL Measures oxygen carrying capacity Low: hemorrhage, anemia
of blood High: polycythemia
Hematocrit 35%-50% Measures relative volume of cells Low: hemorrhage, anemia
and plasma in blood High: polycythemia, dehydration
Red blood cell 4-6 million/mm3 Measures oxygen-carrying capacity Low: hemorrhage, anemia
of blood High: polycythemia, heart disease, pulmonary disease
White blood cell Measures host defense against Low: aplastic anemia, drug toxicity, specific infections
Infant 8,000-15,000/mm3 inflammatory agents High: inflammation, trauma, toxicity, leukemia
4-7 y 6,000-15,000/mm3
8-18 y 4,500-13,500/mm3

Diffential Count
Test Normal value Significance
Neutrophils 54%-62% Increase in bacterial infections, hemorrhage, diabetic acidosis
Lymphocytes 25%-30% Viral and bacterial infections, acute and chronic lymphocytic leukemia, antigen reaction
Eosinophils 1%-3% Increase in parasitic and allergic conditions, blood dyscrasias, pernicious anemia
Basophils 1% Increase in types of blood dyscrasias
Monocytes 0%-9% Hodgkin’s disease, lipid storage disease, recovery from severe infections, monocytic leukemia

Absolute Neutrophil Count (ANC)

Calculation Normal value Significance
(% Polymorphonuclear Leukocytes + % Bands) x Total White Cell Count >1500 <1000 Patient at increased risk for infection;
100 defer elective dental care

Bleeding Screen
Test Normal value Function Significance
Prothrombin 1-18 sec Measures extrinsic Prolonged in liver disease, impaired Vitamin K production,
time surgical trauma with blood loss
Partial thrombo- By laboratory control Measures intrinsic clotting of blood, Prolonged in hemophilia A, B, and C and Von Willebrand’s
plastin time congenital clotting disorders disease
Platelets 140,000-340,000/mL Measures clotting potential Increased in polycythemia, leukemia, severe hemorrhage;
decreased in thrombocytopenia purpura
Bleeding time 1-6 min Measures quality of platelets Prolonged in thrombocytopenia
International Without anticoagulant Measures extrinsic clotting Increased with anticoagulant therapy
Normalized therapy: 1; Anticoagulant function
Ratio (INR) therapy target range: 2-3

Urinalysis
Test Normal value Function Significance
Volume 1,000-2,000 mL/day Increase in diabetes mellitus, chronic nephritis
Specific gravity 1.015-1.025 Measures the degree of tubular Increase in diabetes mellitus; decrease in acute nephritis,
reabsorption and dehydration diabetes insipidus, aldosteronism
pH 6-8 Reflects acidosis and alkalosis Acidic: diabetes, acidosis, prolonged fever
Alkaline: urinary tract infection, alkalosis
Casts 1-2 per high power field Renal tubule degeneration occurring in cardiac failure,
pregnancy, and hemogobinuric-nephrosis

Electrolytes
Test Normal value Function Significance
Sodium (Na) 135-147 mEq Increase in Crushing’s syndrome
Potassium (K) 3.5-5 mEq Increase in tissue breakdown
Bicarbonate (HCO3) 24-30 mEq Reflects acid-base balance
Chloride (Cl) 100-106 mEq Increase in renal disease and hypertension

342 RESOURCE SEC TION

The Handbook of Pediatric Dentistry 343

 Common Pediatric Medications*
COMMON PEDIATRIC MEDICATIONS
Analgesics Antibiotics
Acetaminophen Amoxicillin
Forms: Liquid, tablet, oral disintegrating tablet, caplet, rectal suppository, Forms: Suspension, chewable tablet, tablet, capsule
injectable Usual oral dosage1,2:
Usual oral dosage1,4: Children > 3 months of age up to 40 kg:
Children < 12 years: 10-15 mg/kg/dose every 4-6 hours as needed (maximum 20-40 mg/kg/day in divided doses every 8 hours
90 mg/kg/24 hours5 but not to exceed 2.6 g/24 hours1,4) OR 25-45 mg/kg/day in divided doses every 12 hours
OR Alternative Acetaminophen Dosing Based on Age of Child4 Children > 40 kg & adults: 250-500 mg every 8 hours
OR 500-875 mg every 12 hours
Age Weight Dosage (mg)5
Endocarditis prophylaxis3: 50mg/kg (maximum 2 g) 30-60 minutes
lbs kg before procedure
0-3 months 6-11 2.7-5 40
Amoxicillin clavulanate potassium
4-11 months 12-17 5.1-7.7 80
Forms: Suspension, chewable tablet, tablet
1-2 years 18-23 7.8-10.5 120
Usual oral dosage1,4: (based on amoxicillin component):
2-3 years 24-35 10.6-15.9 160
Children > 3 months of age up to 40 kg: 25-45 mg/kg/day in doses
4-5 years 36-47 16-21.4 240
divided every 12 hours (Prescribe suspension or chewable
6-8 years 48-59 21.5-26.8 320 tablet due to clavulanic acid component)
9-10 years 60-71 26.9-32.3 400 Children > 40 kg & adults: 500-875 mg every 12 hours
11 years 72-95 32.4 - 43.2 480 (Prescribe tablet)

Cephalexin
Children > 12 years and adults: 325-650 mg every 4-6 hours or 1000 mg
Forms: Suspension, tablet, capsule
3-4 times/day as needed (maximum 4 g/24 hours)
Usual oral dosage1,4:
Acetaminophen with codeine Children > 1 year: 25-100 mg/kg/day in divided doses every 6-8 hours
(maximum 4g/day)
Forms: Liquid, tablet
Adults: 250-1000 mg every 6 hours (maximum 4g/day)
Liquids: 120 mg acetaminophen and 12 mg codeine/5 mL (Note the elixir
and solution, but not suspension, contain alcohol) Endocarditis prophylaxis3,4: 50 mg/kg (maximum 2 g) 30-60 minutes
before procedure
Tablet: No. 2: 300 mg acetaminophen and 15 mg codeine
No. 3: 300 mg acetaminophen and 30 mg codeine
Clindamycin
No. 4: 300 mg acetaminophen and 60 mg codeine
Forms: Suspension, capsule, injectable
Usual oral dosage :
2,4
Usual oral dosage2,4:
Children < 12 years: 0.5-1 mg codeine/kg/dose every 4-6 hours as needed; Children: 8-20 mg/kg/day in 3-4 divided doses as hydrochloride
10-15 mg acetaminophen/kg/dose every 4-6 hours as
needed (maximum 90 mg/kg/24 hours but not to OR 8-25 mg/kg/day in 3-4 divided doses as palmitate
exceed 2.6 g acetaminophen/24 hours) 5 Adults: 150-450 mg every 6 hours (maximum 1.8g/day)
OR 3-6 years: 5 mL elixir 3-4 times/day as needed Endocarditis prophylaxis3,4: 20 mg/kg (maximum 600 mg) orally, IM,
7-12 years: 10 mL elixir 3-4 times/day as needed OR IV 30-60 minutes before procedure
> 12 years: 15 mL elixir every 4 hours as needed
Penicillin V Potassium
Adults: Based on codeine 30-60 mg dose every 4-6 hours as needed
(maximum 4 g acetaminophen/24 hours) Forms: Liquid, tablet
OR 1-2 tablets every 4 hours as needed (maximum of 12 tablets/ Usual oral dosage1,4,5:
24 hours). Children < 12 years: 25-50 mg/kg/day in 3-4 divided doses
(maximum 3g/day)
Children > 12 years & adults: 250-500 mg every 6-8 hours

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RESOURCE SEC TION 343

344 The Handbook of Pediatric Dentistry

REFERENCE MANUAL V 33 / NO 6 11 / 12

Analgesics Antibiotics

Ibuprofen
Azithromycin
Forms: Liquid, tablet, injectable
Forms: Suspension, tablet, capsule, injectable
Usual oral dosage1,4:
Children up to 12 years: 4-10 mg/kg/dose every 6-8 hours as needed Usual oral dosage1,4:
(maximum 40 mg/kg/24 hours)5 Children > 6 months up to 16 years: 5-12 mg/kg once daily
OR Alternative Ibuprofen Dosing Based on Age of Child4 (maximum: 500 mg/day)
OR 30 mg/kg as a single dose (maximum 1500 mg)
Age Weight Dosage (mg)
Children > 16 years and adults 250-600 mg once daily
lbs kg
OR 1-2 g as a single dose
6-11 months 12-17 5.1-7.7 50
Doses vary for extended release suspension.
12-23 months 18-23 7.8-10.5 75
Endocarditis prophylaxis1,3: 15 mg/kg 30-60 minutes before procedure
2-3 years 24-35 10.6-15.9 100
(maximum dose: 500 mg)
4-5 years 36-47 16-21.4 150
6-8 years 48-59 21.5-26.8 200
9-10 years 60-71 26.9-32.3 250
11 years 72-95 32.4-43.2 300

Children > 12 years: 200 mg every 4-6 hours as needed

(maximum 1.2 g/24 hours)
Adults: 200 - 400 mg/dose every 4-6 hours as needed (maximum 1.2 g/
24 hours)

Naproxen base
Forms: Suspension, tablet
Usual oral dosage4:
Children > 2 years up to 12 years: 5-7 mg/kg every 8-12 hours as needed
Children > 12 years: 200 mg every 8-12 hours as needed; may take 400 mg
for initial dose (maximum 600 mg/24 hours).
Adults: initial dose of 500 mg, then 250 mg every 6-8 hours as needed
(maximum 1250 mg/24 hours)

* Pediatric dosage should not exceed adult dosage.

References:
1. Mosby’s Dental Drug Reference, 10th edition. Jeske AH, editor. Elsevier/Mosby, St. Louis, Missouri. 2012.
2. Clinical Pharmacology. Gold Standard Inc/Elsevier. Tampa, Fl. Available at: “http://www.clinicalpharmacology-ip.com”. Accessed
June 25, 2011.
3. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: Guidelines from the American Heart Association
Circulation. 2007;116(15):1736-1754. Correction Circulation. 2007;116:e376-e377. Available at: “http://circ.ahajournals.org/cgi/
contentfull/116/15/1736TBL5183095”. Accessed April 11, 2011.
4. Wynn RL, Meiller TF, Crossley HL. Drug Information Handbook for Dentistry, 16th edition. Lexi-Comp, Hudson, Ohio. 2010.
5. Custer JW, Rau RE. The Harriet Lane Handbook, 18th edition. Mosby/Elsevier, Philadelphia, PA; 2009.

DISCLAIMER: Drug information is constantly changing and is often subject to interpretation. While care has been taken to ensure the
accuracy of the information presented, the AAPD is not responsible for the continued currency of the information, errors, omissions, or the
resulting consequences. Decisions about drug therapy must be based upon the independent judgment of the clinician, changing drug
information, and evolving healthcare practices.

34 4 ENDOR SEMENTS

The Handbook of Pediatric Dentistry 345

 AMERIC AN AC ADEMY OF PEDIATRIC DENTISTRY

Management of Medical Emergencies

MANAGEMENT OF MEDICAL EMERGENCIES
For all emergencies
1. Discontinue dental treatment 4. Monitor vital signs
2. Call for assistance / someone to bring oxygen and emergency kit 5. Be prepared to support respiration, support circulation, provide cardiopulmonary
3. Position patient: ensure open and unobstructed airway resuscitation (CPR), and call for emergency medical services

Condition Signs and symptoms Treatment Drug dosage Drug delivery*

Allergic reaction Hives; itching; edema; 1. Discontinue all sources of allergy-causing Diphenhydramine 1 mg/kg Oral
(mild or delayed) erythema–skin, substances Child: 10-25 mg qid
mucosa conjuctiva 2. Administer diphenhydramine Adult: 25-50 mg qid1

Allergic reaction Urticaria-itching, flushing, This is a true, life-threatening emergency Epinephrine 1:1000 IM or SubQ
(sudden onset): hives; rhinitis; 1. Call for emergency medical services 0.01 mg/kg every 5 min
anaphylaxis wheezing/difficulty breathing; 2. Administer epinephrine until recovery or until
broncho-spasm; laryngeal 3. Administer oxygen help arrives1,2
edema; weak pulse; marked 4. Monitor vital signs
fall in blood pressure; loss of 5. Transport to emergency medical facility
consciousness by advanced medical responders

Acute asthmatic Shortness of breath; 1. Sit patient upright or in a 1. Albuterol (patient’s or Inhale
attack wheezing; coughing; comfortable position emergency kit inhaler)
tightness in chest; 2. Administer oxygen 2. Epinephrine 1:1000 IM or SubQ
cyanosis; tachycardia 3. Administer bronchodilator 0.01 mg/kg every
4. If bronchodilator is ineffective, administer 15 min as needed1,2
epinephrine
5. Call for emergency medical services with
transportation for advanced care if
indicated

Local anesthetic Light-headedness; changes 1. Assess and support airway, breathing, Supplemental oxygen Mask
toxicity in vision and/or speech; and circulation (CPR if warranted)
metallic taste; changes in 2. Administer oxygen
mental status–confusion; 3. Monitor vital signs
agitation; tinnitis; tremor; 4. Call for emergency medical services with
seizure; tachypnea; transportation for advanced care if
bradycardia; unconsciousness; indicated
cardiac arrest

Local anesthetic Anxiety; tachycardia/ 1. Reassure patient Supplemental oxygen Mask

reaction: palpitations; restlessness; 2. Assess and support airway, breathing, and
vasoconstrictor headache; tachypnea; circulation (CPR if warranted)
chest pain; cardiac arrest 3. Administer oxygen
4. Monitor vital signs
5. Call for emergency medical services with
transportation for advanced care if
indicated

Overdose: Somnolence; confusion; 1. Assess and support airway, breathing, and Flumazenil 0.01 - 0.02 mg/kg IV (if IV access
benzodiazepine diminished reflexes; circulation (CPR if warranted) (maximum: 0.2 mg); may is not available,
respiratory depression; 2. Administer oxygen repeat at 1 min intervals not may be given IM)
apnea; respiratory arrest; 3. Monitor vital signs to exceed a cumulative dose
cardiac arrest 4. If severe respiratory depression, establish of 0.05 mg/kg or 1 mg,
IV access and reverse with flumazenil whichever is lower)1
5. Monitor recovery (for at least 2 hours
after the last dose of flumazenil) and call
for emergency medical services with
transportation for advanced care if indicated

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RESOURCE SEC TION 345

346 The Handbook of Pediatric Dentistry

REFERENCE MANUAL V 33 / NO 6 11 / 12

For all emergencies

1. Discontinue dental treatment 4. Monitor vital signs
2. Call for assistance / someone to bring oxygen and emergency kit 5. Be prepared to support respiration, support circulation, provide cardiopulmonary
3. Position patient: ensure open and unobstructed airway resuscitation (CPR), and call for emergency medical services

Condition Signs and symptoms Treatment Drug dosage Drug delivery*

Overdose: Decreased responsiveness; 1. Assess and support airway, breathing, and Naxolone 0.1 mg/kg up IV, IM, or SubQ
narcotic respiratory depression; circulation (CPR if warranted) to 2 mg.1,2 May be
respiratory arrest; 2. Administer oxygen repeated to maintain
cardiac arrest 3. Monitor vital signs reversal.
4. If severe respiratory depression, reverse with
naxolone
5. Monitor recovery (for at least 2 hours after
the last dose of naxolone) and call for
emergency medical services with transpor-
tation for advanced care if indicated

Seizure Warning aura–disorientation, 1. Recline and position to Diazepam IV

blinking, or blank stare; prevent injury Child up to 5 yrs:
uncontrolled muscle 2. Ensure open airway and 0.2-0.5 mg slowly
movements; muscle rigidity; adequate ventilation every 2-5 min with
unconsciousness; postictal 3. Monitor vital signs maximum=5 mg
phase–sleepiness, confusion, 4. If status is epilepticus, give diazepam and Child 5 yrs and up:
amnesia, slow recovery call for emergency medical services with 1 mgevery 2-5 min
transportation for advanced care if indicated with maximum=10 mg1

Syncope Feeling of warmth; skin pale 1. Recline, feet up Ammonia in vials Inhale
(fainting) and moist; pulse rapid 2. Loosen clothing that may be binding
initially then gets slow and 3. Ammonia inhales
weak; dizziness; hypotension; 4. Administer oxygen
cold extremities; 5. Cold towel on back of neck
unconsciousness 6. Monitor recovery

* Legend: IM = intramuscular IV = intravenous SubQ = subcutaneous

References:
1. Hegenbarth MA, Committee on Drugs. Preparing for Pediatric Emergencies: Drugs to Consider, American Academy of Pediatrics. Pediatrics
2008;121(2):433-43.
2. Pediatric Advanced Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardio-
vascular Care. Circulation 2010;122:S876-S908.

DISCLAIMER: This information is not intended to be a comprehensive list of all medications that may be used in all emergencies. Drug information is constantly
changing and is often subject to interpretation. While care has been taken to ensure the accuracy of the information presented, the AAPD is not responsible
for the continued currency of the information, errors, omissions, or the resulting consequences. Decisions about drug therapy must be based upon the
independent judgment of the clinician, changing drug information, and evolving healthcare practices.

346 ENDOR SEMENTS

The Handbook of Pediatric Dentistry 347

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348 The Handbook of Pediatric Dentistry

The American Academy of Pediatric Dentistry
The Handbook of Pediatric Dentistry 115
TREATMENT ALGORITHMS

The Handbook of Pediatric Dentistry 113

114 The Handbook of Pediatric Dentistry
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