This document discusses various topics related to managing child dental patients including: 1. Indications for general anesthesia such as severe dental disease or documented allergy to local anesthesia. General anesthesia carries risks so should only be used when necessary. 2. Guidelines for taking radiographs in pediatric dentistry including indications based on history and clinical findings. Radiographs help diagnose oral diseases but timing should consider each child's circumstances. 3. Techniques for administering local anesthesia to child patients including using topical anesthetics, infiltration, and nerve block injections while preparing the child to minimize fear and discomfort. Proper administration is important for painless dental procedures.

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. College of Dentistry
Pedodontic I
Management of Potentially Resistant Child-2-
Radiographic Examination in Pediatric
Dentistry
Local Anesthesia for Dental Child Patient
Dr. Hazem El Ajrami

3. II. General Anesthesia:
If the behavior is unacceptable
following behavior modification and
conscious sedation, one should consider
hospitalizing the patient to provide
treatment under general anesthesia.

4. • Indications:
Severe dental diseases in physically, mentally
or medically handicapped children.
Documented allergy to local anesthesia.
Sustained extensive facial trauma.
Multiple carious and abscessed teeth in very
young children.
• Pre-anesthetic assessment
The anesthetist should be consulted.

5. • Operating theatre environment:
Children should be allowed to wear their own
clothes.
Local anesthetic cream should be placed on the
back of the hand to allow painless insertion of
the canola.
Allowing the parent to be with the child during
induction minimizes anxiety.
Parents should be called into the recovery ward
once the child has woken and is stable.
Normal day-stay recovery is a minimum of 2
hours after the operation.

6. • Fasting instructions:
Children under six years of age:
No solids for 6 hours pre-operation.
No breast milk for 4 hours pre-operation.
No clear fluids for 2 hours pre-operation.
Children older than six years of age:
No solids or liquids for 6 hours pre-
operation.

7. • Undesirable Aspects of General Anesthesia:
General Anesthesia represents a real risk
under any situation.
Hospitalization can be a psychic trauma.
No patient should be exposed to that risk
without sufficient cause.

8. Radiographic Examination in
Pediatric Dentistry

9. • Radiographs are valuable aids in the oral
health care of infants, children, adolescents,
and persons with special health care needs.
They are used to diagnose oral diseases, to
monitor dentofacial development and the
progress of therapy. The timing of the initial
radiographic examination should not be based
only upon the patient’s age, but also each
child’s individual circumstances.

10. • Because each patient is unique, the need for
dental radiographs can be determined only
after reviewing the patient’s medical and
dental histories, completing a clinical
examination, and assessing the patient’s
vulnerability to environmental factors that
affect oral health.

11. • Indications for radiographic examination
according to ADA:
A. Positive historical findings:
1. Previous periodontal or endodontic
treatment.
2. History of pain or trauma.
3. Familial history of dental anomalies.
4. Postoperative evaluation of healing.
5. Remineralization monitoring.

12. B. Positive clinical signs/symptoms:
1. Clinical evidence of periodontal disease.
2. Large or deep restorations.
3. Malposed or clinically impacted teeth.
4. Swelling.
5. Evidence of dental / facial trauma.
6. Mobility of teeth.
7. Sinus tract / fistula.
8. Clinically suspected sinus pathology.
9. Growth abnormalities.

13. 10. Oral involvement in known or suspected
systemic disease.
11. Positive neurologic findings in the head and
neck.
12. Evidence of foreign objects.
13. Pain / and or dysfunction in the TMJ.
14. Facial asymmetry.
15. Unexplained bleeding.
16. Abutment teeth for fixed or removable partial
prosthesis.

14. 17. Unexplained sensitivity of teeth.
18. Unusual eruption, spacing or migration of teeth.
19. Unusual tooth morphology, calcification or
color.
20. Unexplained absence of teeth.
21. Clinical erosion.

15. Guidelines for prescribing dental radiographs
A. New patient.
B. Recall patient.
C. No clinical caries.
D. Periodontal disease.
E. Growth and development assessment.

16. A. New patient:
All new patients to assess dental diseases
and growth and development:
I. Primary Dentition:
Posterior bite-wing examination if
proximal surfaces of primary teeth cannot
be visualized or probed.

17. II. Mixed Dentition:
Individual radio-graphic examination
consisting of periapical / occlusal views and
posterior bite-wings or panoramic examination
and posterior bite-wings.
III. Permanent Dentition:
Individual radiographic examination
consisting of posterior bite-wings and selected
periapicals. A full mouth intraoral radiographic
examination is appropriate when the patient
presents with clinical evidence of generalized
dental disease or a history of extensive dental
treatment.

18. B. Recall patient: Clinical caries or high-risk
factors for caries:
I. Primary & Mixed Dentition:
Posterior bite-wing examination at 6
month intervals or until no carious lesions
are evident.
II. Permanent Dentition:
Posterior bite-wing examination at 6 to
12 month intervals or until no carious
lesions are evident.

19. C. No clinical caries and no high-risk factors
for caries:
I. Primary Dentition:
Posterior bite-wing examination at 12
to 24 month intervals if proximal surfaces
of primary teeth can not be visualized or
probed.

20. II. Mixed Dentition:
Posterior bite-wing examination at 12 to
24 month intervals.
III. Permanent Dentition:
Posterior bite-wing examination at 18 to
36 month intervals.

21. D. Periodontal disease or a history of
periodontal treatment:
I. Primary, Mixed & Permanent Dentition:
Individualized radiographic
examination consisting of selected
periapical and/ or bite-wing radiographs
for areas where periodontal disease (other
than nonspecific gingivitis) can be
demonstrated clinically.

22. E. Growth and development assessment:
I. Primary Dentition:
Usually not indicated.
II. Mixed Dentition:
Individualized radiograpbic
examination consisting of a periapical/
occlusal or panoramic examination.
III. Permanent Dentition:
Periapical or panoramic examination
to assess developing third molars.

23. Local Anesthesia for Dental
Child Patient

24. • One of the most important factors in successful
dental service for children is the control of
pain during the treatment. The procedure
should be accomplished with a minimum
degree of discomfort. Local anesthesia is the
most common method, of pain control.
Effective local anesthesia allows dental
procedures to be carried out painlessly.

25. • This method of eliminating pain is painful itself
and can be very distressing to the child. Most
cavity preparations, vital pulp therapy,
extraction of teeth and surgical procedures
require administration of local anesthetics. In
children dentistry, special techniques are
required. The procedure should be prepared and
given properly.

26. • Topical anesthesia:
The application of topical (surface)
anesthetic on the injection site can render
needle insertion painless. There is some
evidence that the use of topical anesthetic
paste (ointment or cream) is better than the use
of topical anesthetic spray.

27. • An acceptable topical anesthetic for oral use
should be:
A. Of pleasant taste.
B. Fast acting and effective.
C. Causes no irritation.
• Topical anesthetics can be provided as paste
(ointment, cream or gel) or solution in
pressurized container (spray) or cotton pellets
or even adhesive disks.

28. • Local anesthesia techniques:
1. Preparation of the child dental patient:
The child will be told that to treat his
tooth properly and comfortably, this tooth is
going to be "put to sleep". At first, "a paste
will be applied to put the gum to sleep". The
parents, if present in the operating room,
should be informed not to interfere or
comment or ask their child to open, or close
his mouth or even try to help by encouraging
words.

29. 2. Application of the topical anesthetics:
 To act effectively, topical anesthetic paste has
to be applied to dried mucous membrane.
Topical anesthetic spray splatters and reaches
the soft palate causing gagging sensation. Use
one end of cotton wool roll to dry the site of
insertion and the other end being used to
apply the paste.
 Allow time (about 2 minutes) to work before
the injection is given "to wash this paste
away".

30. 3. Injection the local anesthetic solution:
Support the head and apply pressure to
injection site using your finger or the blunt
end of instrument just prior to injection.
Stretch the tissues prior to insertion of the
needle; this will result in easier penetration.
The concealment of the syringe from the
child is recommended.

31. • Your dental assistant places the syringe hand in
a working position before the injection and
receives it when the injection is complete.
Inject the first drop on penetration, wait for
moment, then inject slowly.

32. • When the injection is completed, tell the child
what he is going to feel (numbness, tingling,
warmth, or fells big or fat, etc.) and assure him
using hand mirror. Clinical experience shows
that about 1.0 ml. of the 1.8 ml. carpule is
adequate for achieving profound anesthesia in
children under the age of 10 years. Enough time
is allowed before starting any procedure.

33. • The needle used should be of fine gauge
(gauge 27 for aspirating and gauge 30 for non-
aspirating technique). A fine needle will cause
the least discomfort on penetration. Pass the
syringe below the child's chin and out of the
field of his vision.

34. • All maxillary and lower anterior teeth can be
anesthetized by filtration anesthesia using
short or extra-short needle of fine gauge.
Lower primary molars can be anesthetized by
infiltration anesthesia or inferior dental nerve
block, but in the very young infiltration is
preferred. The resulting anesthesia permits
procedure other than extraction to be carried
out painlessly.

35. • In the case of extraction in upper jaw, palatal
injection should be avoided as it is impossible to
give this without causing discomfort, the
alternative is to wait for the buccal infiltration to
have its effect and then to inject into the palatal
aspect of the interdental papillae from the buccal
side distal and mesial to the tooth to be
extracted. This is called intrapapillary injection.
Now inject into the blanched area on the palate
for a nearly painless palatal anesthesia.

36. • When the buccal infiltration anesthesia is used
in the lower jaw, lingual anesthesia will be
necessary for any extraction. An intrapapillary
injection as mentioned with maxillary teeth
will suffice.

37. • Nerve block anesthesia in the mandible:
This method is used for all procedure in the
mandibular molars (primary and permanent) in
the children except for the very young. Block
injection anesthesia larger area with fewer
injections and is preferred when localized
infection exists in the area of the infiltration site.

38. • Technique:
It will be found that a little topical anesthetic
paste at the end of a cotton wool roll in contact
with the dried retromolar area and with the
patient holding the cotton roll between the teeth
is an acceptable method of localizing the topical
anesthetic paste.

39. • The mandibular foramen is situated at a lower
level than the occlusal plane of the primary
teeth of the child patient. Therefore the
injection must be made slightly lower and
more posteriorly than for the adult. The size of
the mandible is also smaller than that of the
adult.

40. Thank You