Travis Nelson

Pediatric dental sedation: challenges and opportunities.

High levels of dental caries, challenging child behavior, and parent expectations support a need for sedation in pediatric dentistry. This paper reviews modern developments in pediatric sedation with a focus on implementing techniques to enhance success and patient safety. In recent years, sedation for dental procedures has been implicated in a disproportionate number of cases that resulted in death or permanent neurologic damage. The youngest children and those with more complicated medical backgrounds appear to be at greatest risk. To reduce complications, practitioners and regulatory bodies have supported a renewed focus on health care quality and safety. Implementation of high fidelity simulation training and improvements in patient monitoring, including end-tidal carbon dioxide, are becoming recognized as a new standard for sedated patients in dental offices and health care facilities. Safe and appropriate case selection and appropriate dosing for overweight children is also paramount. Oral sedation has been the mainstay of pediatric dental sedation; however, today practitioners are administering modern drugs in new ways with high levels of success. Employing contemporary transmucosal administration devices increases patient acceptance and sedation predictability. While recently there have been many positive developments in sedation technology, it is now thought that medications used in sedation and anesthesia may have adverse effects on the developing brain. The evidence for this is not definitive, but we suggest that practitioners recognize this developing area and counsel patients accordingly. Finally, there is a clear trend of increased use of ambulatory anesthesia services for pediatric dentistry. Today, parents and practitioners have become accustomed to children receiving general anesthesia in the outpatient setting. As a result of these changes, it is possible that dental providers will abandon the practice of personally administering large amounts of sedation to patients, and focus instead on careful case selection for lighter in-office sedation techniques.

Predictors of Unmet Dental Need in Children With Autism Spectrum Disorder: Results From a National Sample

OBJECTIVE Unmet dental need in children with autism spectrum disorder (ASD) is common. We tested hypotheses that lacking a medical home or having characteristics of more severe ASD is positively associated with having unmet dental need among children with ASD. METHODS Using data from the 2009 to 2010 National Survey of Children with Special Health Care Needs, we analyzed 2772 children 5 to 17 years old with ASD. We theorized that unmet dental need would be positively associated with not having a medical home and having characteristics of more severe ASD (eg, parent reported severe ASD, an intellectual disability, communication, or behavior difficulties). Prevalence of unmet dental need was estimated, and unadjusted and adjusted odds ratios, 95% confidence intervals, and P values were computed using survey methods for logistic regression. RESULTS Nationally, 15.1% of children with ASD had unmet dental need. Among children with ASD, those without a medical home were more apt to have unmet dental need than those with a medical home (adjusted odds ratio, 4.46; 95% confidence interval, 2.59-7.69). Children with ASD with intellectual disability or greater communication or behavioral difficulties had greater odds of unmet dental need than those with ASD without these characteristics. Parent-reported ASD severity was not associated with unmet dental need. CONCLUSIONS Children with ASD without a medical home and with characteristics suggestive of increased ASD-related difficulties were more apt to have unmet dental need. Pediatricians might use these findings to aid in identifying children with ASD who might not receive all needed dental care.

Educational and therapeutic behavioral approaches to providing dental care for patients with Autism Spectrum Disorder

PURPOSE Autism Spectrum Disorder (ASD) is a condition which most dentists will encounter in their practices. Contemporary educational and behavioral approaches may facilitate successful dental care. METHODS A literature review was conducted for relevant information on dental care for children with ASD. RESULTS Educational principles used for children with ASD can be applied in the dental setting. Examples include: parent involvement in identifying strengths, sensitivities, and goal setting; using stories or video modeling in advance of the appointment; dividing dental treatment into sequential components; and modification of the environment to minimize sensory triggers. Patients with ASD are more capable of tolerating procedures that they are familiar with, and therefore should be exposed to new environments and stimuli in small incremental steps. CONCLUSIONS By taking time to understand children with ASD as individuals and employing principles of learning, clinicians can provide high quality dental care for the majority of patients with ASD.

The Role of Sedation in Contemporary Pediatric Dentistry

Procedural sedation offers an effective and humane way to deliver dental care to the young, anxious child and to those with extensive treatment needs. Delivery of sedation requires thorough understanding of its indications and contraindications, patient assessment, pharmacology, monitoring, and office protocol. Safe and successful outcomes depend on a systematic approach to care, and the ability to manage unintended cardiopulmonary events.

The Continuum of Behavior Guidance

Behavior guidance is a continuum of techniques, basic and advanced, fundamental to the provision of quality dental care for pediatric patients. This practice must be individualized, pairing the correct method of behavior guidance with each child. To select the appropriate technique, the clinician must have a thorough understanding of each aspect of the continuum and anticipate parental expectations, child temperament, and the technical procedures necessary to complete care. By effectively using techniques within the continuum of behavior guidance, a healing relationship with the family is maintained while addressing dental disease and empowering the child to receive dental treatment throughout their lifetime.

Temperament as a Predictor of Nitrous Oxide Inhalation Sedation Success

&NA; Little is known about implications of temperament for children who receive nitrous oxide inhalation sedation (N2O/O2) for dental care. The aim of this study was to investigate whether child temperament is associated with success in N2O/O2. Child‐caregiver dyads were enrolled from patients aged 36‐95 months receiving dental care with N2O/O2 at a university‐based pediatric dental clinic. To assess child temperament, 48 caregivers completed the Childrens Behavior Questionnaire Short Form. Patient behavior was abstracted from Frankl scores recorded in the patients chart. The overall behavioral failure rate was 15% (n = 7/48). There was no significant difference in sedation outcome associated with sex, health, insurance status, or complexity of treatment provided. Sedation outcome was significantly associated with the broad temperament domain of Effortful Control and its subscales Attentional Focusing and Inhibitory Control. The Negative Affectivity subscales of Frustration, Sadness, and Soothability and the Extraversion/Surgency subscales Activity and Impulsivity were also significantly associated with sedation outcome. The results of this study suggest that Effortful Control is associated with behavior during dental treatment with N2O/O2. The subscales of Attention Focusing, Inhibitory Control, Frustration, Fear, Sadness, Soothability, Activity, and Impulsivity may also be important determinants of child behavior during dental treatment.