Child’s Play

Because treatment can be a challenge when it comes to kids, clinicians can benefit from having a variety of pain management options on hand. This is where you come in. We survey strategies in pain and behavior management that can be successfully implemented in the pediatric dental setting.

Recently, video of a child strapped to a papoose board, screaming hysterically while a dentist performed a procedure, went viral. The dentist was accused of abuse. Such stories, and the video itself, are disturbing — certainly not the image most pediatric dentists shoot for. While this case is extreme, methods used to restrain children for dental work can look alarming, despite the fact that they may be used in the interest of safety for both the child and staff.

To be sure, performing dentistry on uncooperative or frightened children has its challenges compounded by an epidemic of childhood caries. After all, the combination of needles and high-speed drills with flailing arms and jerking heads is a recipe for disaster. But there are ways of dealing with child patients that don’t conjure images of Steve Martin from “Little Shop of Horrors.”

But how does a practitioner tell the difference between fear, anxiety, downright orneriness, and true pain? According to the American Academy of Pediatric Dentistry (AAPD), because we lack any way to truly measure pain, clinicians must be attentive to changes in patient behavior that might indicate pain. By listening to the child and effecting modifications to reduce pain, the clinician has the best shot at cultivating a good future relationship with the child patient.1

VICTOSHAFOTO/ISTOCK/THINKSTOCK

VICTOSHAFOTO/ISTOCK/THINKSTOCK

PRIMARY CONSIDERATIONS

Positive dental experiences for young children have much to do with a positive outlook about the experience in adults. Perceived pain, after all, is the stepchild of fear and anticipation. To this end, it may be helpful for an office to provide pre-visit information to parents to help them best prepare their child for the trip to the dentist.

John Liu, DDS, who practices pediatric dentistry in Issaquah, Washington, is on the attending staff at Seattle Children’s Hospital, and serves as a national spokesperson for the AAPD. In his opinion, family members can very much affect the perception of the dentist in young children. Says Liu, “Parents may have had bad dental experiences and are fearful themselves of seeing the dentist. Often the children can sense this fear in their parents. Older siblings may instill fear in younger siblings by telling them that the dentist is going to give them a ‘shot’ with a really long, big needle.”

Liu notes several additional reasons that pediatric dental treatments materialize into challenges for clinicians. “Children are getting cavities at much younger ages — under age 3 — and thus are not capable of listening to and cooperating with a stranger,” says Liu, adding that pain and fatigue can definitely magnify behavioral problems.

Says Liu, “If it is a trauma situation with a broken tooth, they are already hurting and scared about what it is we might have to do to ‘fix them up.’ Or if a cavity is already really large, causing pain, and badly infected, they’ve already had difficulties sleeping, eating, and are tired and worn out. Getting cooperation and being able to reason with a sleep-deprived, hungry child can be extremely difficult.”

Sarat Thikkurissy, DDS, director of the residency program, Division of Pediatric Dentistry and Orthodontics at Cincinnati Children’s Hospital Medical Center, and also an AAPD national spokesperson, says the key to dentistry is prevention. “We recommend all children have a dental home by 12 months of age so that a dentist can provide appropriate and individualized anticipatory guidance for parents,” he explains, adding, however, that despite the best preventive efforts, cavities can still progress, and children can experience pain. And this requires treatment.


Point of Sale | KID STUFF FOR ANESTHESIA

  • Topical agents, available in kid-friendly flavors, are used to numb the injection site prior to the prick of the needle, enhancing comfort.
  • Buffering agents may be used with anesthetic solutions to take the sting out of the highly acidic formulations.
  • An assortment of needles can be used in pediatric dentistry, and clinicians should have a range of them on hand.
  • Vibration devices and computer-controlled injection delivery systems can be employed to lessen injection discomfort through distraction and slow delivery.
  • A newly FDA-approved nasal spray can be used to numb maxillary anterior teeth in children over 88 pounds.
  • Another needleless option delivers anesthesia via the sulcus for infusion across the periodontal ligament.

TOPICAL AGENTS

Because anesthetic solutions are more acidic than the human body, they may sting upon injection. To lessen the sting and ease the prick of the needle when administering a local injection, topical anesthetics come in handy.

“Most children are able to tolerate dental procedures with topical anesthetic agents being placed first before any local anesthetic injection is given,” Liu says.

According to the AAPD, these agents, available as gels, sprays, liquids, ointments, aerosols and patches, are effective in numbing surface tissues up to 3 mm in depth. They work courtesy of active ingredients such as lidocaine, benzocaine, tetracaine, or prilocaine. Typically available in child-friendly flavors, they may offer the added benefit of minimizing salivation.

LOCAL INJECTIONS

When a local injection is given, it doesn’t mean that the clinician just sticks in the needle and blasts away. According to Thikkurissy, a combination of techniques may be employed. “Again,” he says, “it is based on the child’s individualized needs.”

Anesthetic solutions commonly used today include lidocaine, mepivacaine, articaine, prilocaine and bupivacaine.2 Besides the use of topicals, there are other ways of making local injections more comfortable. For instance, buffering anesthetic solutions is used as a way of reducing their inherent acidity to take the sting out by raising the solutions’ pH just prior to injection.

Technique also can greatly affect injection comfort. The best injections are said to be those that are delivered slowly. To this end a number of devices on the market are geared to dispense small increments of solution at a time. Others offer computer-controlled flow-rates to deliver the utmost in comfort.

Liu notes that some of these devices may appear less intimidating than a traditional needle and syringe, while also offering better comfort. One in particular, he says, delivers the local solution slowly, a drop at a time, in a slow, deliberate manner. “Often,” he says, “when using the traditional syringe, the local anesthetic is delivered too quickly or too forcefully, which can be hugely stimulating and painful to the child.”

Vibration is another tactic used. By jiggling the cheek, or using a vibrotactile device, a clinician can capitalize on the gate control theory, which holds that the brain can only respond to one stimulus at a time.

Needles are, of course, a necessary component of injections for the most part. According to the AAPD, dental needles used in children are available in three lengths: long (32 mm), short (20 mm), and ultrashort (10 mm). Needle gauges range from size 23 to 30. Short needles are used for injections into soft tissue less than 20 mm thick, while longer needles are for deeper injections. So your dental customers will need to have an assortment on hand. The AAPD further recommends the use of aspirating syringes.2

But recently, needleless options have been emerging. One, a nasal spray, has been approved by the FDA for anesthetizing upper teeth of children weighing more than 88 pounds. Another delivers anesthesia via the sulcus for infusion across the periodontal ligament. Other innovations include jet injectors, which use compressed air to shoot liquid with enough force to penetrate skin (remember the hypospray used in “Star Trek”?).

BEYOND THE LOCAL

One of the most basic kinds of sedation is nitrous oxide. Often known as “laughing gas,” this is a mix of nitrous oxide gas and oxygen, which is delivered via a mask that fits over the nose. It provides a mild form of sedation, allowing the patient to remain conscious but relaxed.

Says Liu, “Quite a number of mildly anxious children can be treated with the addition of nitrous oxide before the placement of topical anesthetics, and throughout the dental procedure. Sometimes, a mild oral sedative can be given in conjunction with the nitrous oxide for those who are slightly more anxious and only have a few teeth that need work.”

But when these measures fail to calm kids to the point that they can be safely treated, deeper sedation is another option. Says Liu, “For the relatively small number of either very young or very anxious children — and/or a child with too many cavities to be done in one or two visits — deep IV sedation or general anesthesia with an anesthesiologist working with the dentist is necessary.”


TELL-SHOW-DO

KEITH BROFSKY/ISTOCK/THINKSTOCK

KEITH BROFSKY/ISTOCK/THINKSTOCK

As AAPD national spokesperson Sarat Thikkurissy, DDS, notes, “Dental pain is highly individualized, and can present in any number of ways, including behavioral changes such as anxiety and fear.” But Thikkurissy also points out that pediatric dentists receive training in child development and communication with children of all ages and abilities to help them deal with such manifestations.

One popular technique employed in dental offices today is called “Tell-Show-Do.” This form of operant conditioning uses positive reinforcement and the slow introduction of instruments.

In the course of this strategy, the clinician might tell the child, in simple language, about the procedure and the steps involved.

The show part of the equation allows the child a chance to touch or examine the instruments or equipment to be used, though sharp instruments might not be shown. For instance, the child might get the opportunity to check out the air and water “pistol” and to feel the whir of a rubber cup on his or her fingers. The goal is to build the child’s confidence through familiarity paired with positive reinforcement.

Then, when the child is relatively calm, the dentist can proceed — and do the treatment. Tell-Show-Do is said to be one of the most effective methodologies in the pediatric dentist’s arsenal.


SEDATION

Many pediatric dentists offer some form or other of sedation, including preoperative anxiolysis, involving medications designed to curtail anxiety before treatment. The administration of medication to initiate conscious, or moderate, sedation can be helpful with very young or apprehensive children, or those with special needs. The child may become drowsy under this type of sedation, and may even fall asleep, but he or she will remain conscious enough to maintain a patent airway independently, and respond to verbal commands.

Deep conscious sedation is a strategy that is particularly valuable for some patients with special needs. It involves administration of the sedative solution via intravenous (IV) methods. Under this type of anesthesia, patients’ conscious states may be depressed, or the patients may lose consciousness. Their ability to maintain a patent airway may be compromised compromised, and they may not be able to respond to verbal commands.

Finally, general anesthesia via IV sedation puts children to sleep for the duration of the procedure. Though risks involving anesthesia of this type are always greater than with other sedation options, the benefits may outweigh those risks. The alternative may involve the use of physical restraint, multiple stressful appointments, and possible physical injury and psychological trauma. In contrast, under general anesthesia, a child with possible behavioral issues can have multiple issues addressed while he or she is asleep.

Says Thikkurissy, “The technique used and agreed upon by the dental team and the parent is individualized and based on the child’s chronologic age or, more critically, cognitive ability. Preverbal children under age 3 often don’t have the developmental ability to cooperate for the direction we give in dental visits. The only absolutely effective technique is general anesthesia. But, as with all techniques, there are risks and benefits. The risks for general anesthesia can be considerable, particularly for children with special health needs, or younger children. It is not a consequence-free decision and pediatric dentists explain those risks and benefits.”

Lately, there has been a trend to favor conscious sedation over deeper methods requiring intubation. This is partly because the need for a tracheal tube or means to maintain a patent airway can inhibit the spatial requirements for dental treatment. In addition, deeper forms of sedation require an anesthesiologist to be on staff, or a trip to the hospital. But even with moderate levels of sedation, it is not unknown for children, in particular, to slip into deeper sedation, which requires increased vigilance on the part of clinical personnel.3

NEW STRATEGIES

Says Thikkurissy, “Pediatric dentists use varying techniques to protect the developing psyche of the child from the morbidities of dental infections while at the same time keeping them safe and stable.”


LEXICON

  • Anxiolysis: Minimal sedation.
  • Aspirating syringe: A hypodermic syringe capable of being drawn back to check for blood to ensure anesthetic won’t be injected into a blood vessel.
  • Dental home: A go-to dental office, ideally established at an early age.
  • Papoose board: A restraining device for children.
  • pH: Measures the acidity or alkalinity of a substance.
  • Vibrotactile: Refers to a device that elicits the sense of vibration to the touch.

Fortunately, new devices and techniques are continually emerging. Some new strategies are not yet ready for pediatric applications. But, Thikkurissy says, new diversions such as virtual-reality goggles are a big help in distracting children from treatment with their favorite movies or video games.

There’s no doubt child patients can challenge dental clinicians, who are only seeking to relieve their pain. But thanks to forward-thinking research as well as the devices and techniques currently available, there is a real chance they can turn mind-numbingly stressful situations into child’s play.

Featured photo by ELLA/ISTOCK/THINKSTOCK; WESTLIGHT/ISTOCK/THINKSTOCK

REFERENCES

  1. American Academy of Pediatric Dentistry. Guideline on Behavior Guidance for the Pediatric Dental Patient. Available at: aapd.org/media/Policies_Guidelines/G_BehavGuide.pdf. Accessed December 3, 2016.
  2. AAPD. Guideline on Use of Local Anesthetics for Pediatric Dental Patients. Available at: aapd.org/media/policies_guidelines/g_localanesthesia.pdf. Accessed December 3, 2016.
  3. AAPD. Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures. Available at: aapd.org/media/Policies_Guidelines/G_Sedation.pdf. Accessed December 3, 2016.

MENTOR January 2017; 1(7):18-20, 22-23.

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