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Pediatric patients come with many challenges, but it’s up to clinicians to give them the treatment they deserve.
Anyone who has ever even attempted to look into a child’s mouth can readily understand the challenges that come with performing dentistry on a pediatric patient.
As we all know, the practice of dentistry comes with its own set of unique and complicated challenges. However, when you factor in the aspect of a potentially 50 percent smaller aperture, greater sensitivity and a “moving target,” we’re frequently confronted with a clinical situation that even Batman or The Avengers couldn’t overcome.
However, I think that pediatrics offers us unique opportunities that more than make up for the unique challenges. By that I’m talking about improving the experience for our youngest patients. You may hear the same stories in your office that I do.
Usually when I’m about to meet or treat a very anxious patient, those who are willing to talk about their fears will normally start with the following line, “You know, it’s nothing personal toward you, but one time when I was a kid…” What then follows is a story of a terrible and frightening childhood dental experience.
One of my career goals is that when I’m retired there won’t be a patient somewhere telling their new dentist that the reason for their dental phobia is due to some terrible incident that happened in my office. I truly feel we owe that to our profession and especially to those little “adults of tomorrow” whose trust and future dental fears (or lack thereof) depend solely on us.
With those thoughts in mind, this month let’s explore some technology that can help us do the best we can for our young patients.
One of the best things we have going for us these days is the ability to utilize technology to keep busy minds busy.
In my office, we have computers all over the place, even monitors over the patient. Utilizing a dual-monitor system in the operatory is terrific in a lot of ways; one of them is that it allows the over-the-patient monitor to provide a distraction.
One of the best, and least expensive, things we’ve invested in is a commercial Netflix account. Unlike TV, Netflix starts the show at the beginning no matter what time the appointment starts. Younger patients have lots of cartoon and computer-generated shows to watch while tweens get a big kick out of “Friends” and “The Office.”
We can also play a favorite Blu-ray disc or stream their favorite music or YouTube channel. Utilizing headphones helps give them a personalized and isolated experience. The proliferation of Bluetooth even allows for us to eliminate the bothersome cords.
Of course there are other options too. Apple TV and Amazon Prime Video are both good solutions. The point is, if you can get a youngster’s mind on anything other than dentistry, your odds of a better appointment increase substantially.
Kids hate the bright lights we use, so we purchase very dark safety glasses for them. Some of the best we’ve found are the Dark Grey EyePRO Smoke Safety Goggles that we purchase at Home Depot. A package of six costs $6.78. They’re affordable enough that we offer them to the patient as a giveaway when we’re done. If the arms are too long, we can quickly cut them to make them shorter with a disc in a slow speed. The kids really like them and they do an outstanding job of dimming the lights. I have no idea why, but letting the kids take them home as a gift seems to be a really big deal for them.
I routinely tell my patients that if I could get rid of injections in dentistry, I wouldn’t miss it. My patients always reply they wouldn’t miss it either. However, for the foreseeable future the needle will continue to be an integral part of many dental procedures. Since we can’t eliminate it, how about considering some ways to at least make it more tolerable?
There are three things that cause pain during a dental injection: needle stick, burn from pH difference and pressure from injection. There are ways to deal with all three of those.
To help eliminate the needle stick pain, many dentists use some type of topical anesthetic. Most of these are 20% benzocaine in either a gel or a spray. The thing about benzocaine is that it’s effective, but not overly so. By that I mean it provides some anesthesia, but the effect isn’t necessarily profound. They’re also flavored, but the flavoring can sometimes cause problems of its own since the patient has a hard time tolerating it.
Due to the chemical composition of anesthetics, they have a flavor in the bitter spectrum and that requires a bitter flavor to try and bury the anesthetic distaste within. The problem, of course, is trying to get the patient to tolerate the flavor for the standard two minutes while the chemical takes effect. However, there is a topical that provides profound anesthesia and it’s ideal for helping with the painless injection for our pediatric patients.
It’s called EMLA (Eutectic Mixture of Local Anesthetics) and is a cream dispensed from a tube. EMLA is mixture of 2.5% prilocaine and 2.5% lidocaine. Dry the mucosa with gauze and apply a very small amount with a cotton-tipped applicator. Keep the high-speed vacuum close by so that the patient doesn’t swallow any and let it set for two minutes. When the two minutes are up, wash it away and proceed with the injection. You’ll be pleased with the level of soft tissue anesthesia.
EMLA was developed for use with venipuncture and helping fearful patients requiring a blood draw or an IV. However, someone much smarter than me had the epiphany that if it worked well on intact epidermis, it would work extremely well on intact mucosa. Fortunately, a two-minute wait time results in a very profound topical result. EMLA is not inexpensive, but for limited applications, it can truly be a game-changing product.
The sting of the first few seconds of injection is also unpleasant. That’s due to the fact that the pH of our injectable locals is about the same as lemon juice. The penetration and effectiveness of EMLA can help with this, but there are also several companies that offer ways to buffer the anesthetic prior to injection. Onpharma and Anutra are both companies currently in this space. Buffered anesthetics are much closer to the body’s natural pH, which helps eliminate the sting, and the higher pH also takes effect faster.
The final piece of the anesthesia puzzle is pressure. For several years now, I’ve given my injections with the STA device from Milestone Scientific. The human body is very pressure sensitive and reacts to an increase in pressure with a pain response. The STA, and its little brother The Wand® (both from Milestone Scientific), use the standard dental anesthetic cartridge. Their trick is that they inject super slowly, which, instead of creating a 1.7 to 1.8cc bolus of anesthetic, allows the anesthetic to slowly diffuse into the tissue - meaning there’s very little pressure and consequently minimal, if any, pain.
In order to make the process of prepping easier, it’s often necessary to think “outside the box,” or perhaps in this case “outside the mouth.” By that I mean think about what you’ll be putting into the patient’s mouth before you ever get to that stage.
Since the size of a child’s mouth is much smaller than an adult’s, it’s often a good idea to think about the size of our instruments when treating children. Some of the handpieces we have in our armamentarium are a bit large even for adults, so why not use a handpiece that’s specifically designed for a child?
Air abrasion has been around in clinical dentistry for more than 20 years and it still remains a viable alternative to the handpiece. CrystalMark has the CrystalAirTM DV-1 Dental Air Abrasion Device. The DV-1 uses compressed air and a spray of aluminum oxide particles to basically “sand blast” the caries out of the tooth structure - normally without any pain at all. The device is connected to the office compressed air supply and preps without the use of a rotary handpiece or anesthetic. There’s no vibration and no handpiece whine. It also provides a very good surface for bonded restorative procedures.
For those interested, there’s also the hard tissue laser. There are a few of these on the market and they all work well. They painlessly remove caries and hard tissue without the use of a rotary handpiece. There’s no vibration - only air and water spray - so that greatly reduces the anxiety caused by the whine of the handpiece.
Once the tooth is adequately prepared, it’s important to adequately restore. As we all know, pediatric patients have some unique restorative challenges and they don’t always have the best home care.
Because of that, it can be a tremendous advantage to utilize restorative materials that work well in less than ideal conditions and also keep things stabilized and caries free.
To help in that regard, there are a couple of restorative materials that I turn to on a regular basis. Both are glass ionomer restoratives and work extremely well in the primary dentition.
The first is PhotacTM Fil Quick. It’s a resin-modified glass ionomer that comes in an AplicapTM delivery system that guarantees a perfect mix every time. The material tolerates a moist environment (a must in a child’s mouth), is biocompatible, and has excellent radiopacity and fluoride release.
It’s also dual cure and has a nice long working time, which allows you to manipulate placement with hand instruments before initiating the cure with a curing light.
The second is GC EQUIA Forte®. It is also a glass ionomer and has a new glass hybrid formulation that builds a high strength restorative. The result is a tougher resin matrix. It’s not sticky and it’s easily packable while also having good resistance to wear that we often battle with glass ionomer materials. And, of course, it has high fluoride release and works well in a moist environment.
Finally, we come to the restorative material for the tough cases. NuSmile has an affordable MTA that sells under the brand name NeoMTATM. This material is an affordable option for those times when decay exceeds your standard operative regimen. We usually think of MTA as something we reach for in cases of endodontic perforation or apical surgery. However, NeoMTA is a material you’ll find yourself reaching for during deeper primary caries cases.
Children deserve our very best and yet the unique challenges they present make our best sometimes challenging to attain. However, we owe it to them. The nervous child of today is the terrified adult of tomorrow. They end up passing those fears onto their children and those continuing fears also make it difficult for our peers of tomorrow to treat.
By ensuring today’s children have the best possible experience, we’re helping them be better able to trust dentists in the future, and that can change their overall health for a better overall quality of life. Hopefully these recommendations can help you to make a difference in the lives of your pediatric patients and help you to perform to the best of your ability as well.