Pediatric Behavior Management, Nitrous Oxide & Local Anesthesia

1. Pediatric Behavior Management, Nitrous Oxide & Local Anesthesia Dr. Ha T. Jacklynn Thai Board Certified Pediatric Dentist Associate Professor, University of California, San Francisco Department of Pediatric Dentistry HRSA Program: Pediatric Dentistry in Hygiene Dentistry 24700 Calaroga Ave. Suite 104 ~ Hayward, CA 94545 ~ 510.785.9295

2. Pediatric Behavior Management Modalities

3. No intervention • Communication based guidance • Positive pre-visit imagery • Direct observation/modeling • Tell show do (TSD) • Ask Tell Ask • Voice control • Positive reinforcement • Parent presence/absence • Pharmacological/advanced based guidance • Local anesthesia • Nitrous oxide • Protective stabilization • Oral conscious sedation • IV/General/Deep sedation

4. Permission • CONSENT • CONSENT • CONSENT

5. Background • Recognition of the type of behavior/personality your patient has • Recognition of parental expectations • Presence or absence of dental pain • Previous experience • Medical • Dental • Grooming

6. Goal • Behavior management techniques are used to alleviate anxiety, nurture a positive dental attitude, and perform quality oral health care safely and efficiently for infants, children, adolescents, and persons with special needs • Preservation of a positive experience and positive psyche Source: American Academy of Pediatric Dentistry – Clinical Practice Guidelines 2016-2017 Publication

7. Nitrous Oxide • Also known as laughing gas • Colorless, virtually odorless • Analgesic properties • Anxiolytic properties • CNS depression • Euphoric induction • Little effect on respiratory system • Rapid intake, rapid recovery • Extremely soluble to lung tissue  diffusion hypoxia • Minimal impairment to reflexes therefore protects gag/cough reflex • No recorded fatalities or morbidity if used in proper concentrations • Always given concurrent with oxygen – fail safe

8. Indications/Contraindications • Indications • Fearful, anxious patient • Special health care needs • Strong gag reflex • Lengthy, extensive treatment • Contraindications • Chronic pulmonary obstructive disease • Severe emotional disturbances • First trimester of pregnancy • Treatment with bleomycin sulfate (chemo agent) • Methylenetetrahydrofolate reductase deficiency • Cobalamin (B12) deficiency

9. Other Considerations • Monitoring • Considered to be a mild sedation • Clinical observation • Side effects • N + V • Diffusion hypoxia • Other uses • Medical • Food processing propellant • Semiconductor manufacturing • Chemical manufacturing • Auto racing engine injection • Abuse

11. Local Anesthesia • Types • Procaine  Novacain • Mepivacaine (Carbocain) • Lidocaine (Xylocaine) • Articaine (Septocaine) • Benzocaine • Added vasoconstriction (epinephrine)

12. Things to Consider • Proper administration • Overdose amounts • Pregnancy • First trimester  no vasoconstrictor • No Prilocaine  leads to methhemoglobinemia • Lactation effects • Lidocaine is considered the safest

13. Maximum Dose Calculation ____ lbs x kg x mg x carp lbs kg mg 40 lbs x 1 kg x 4.4 mg x 1 carpule = 2.35 carp 2.2 lbs 1 kg 34 mg

14. Side Effects • Biphasic reaction • Excitation followed by depression • Toxicity • Dizziness • Anxiety • Confusion • Blurred vision • Drowsiness • Ringing in ears • Muscle twitching • Heart palpitations followed by bradycardia • Seizure activity • Unconsciousness • Respiratory arrest • Allergies • Itchy • Swelling • Paresthesia (partial or full) • Post-operative maintenance and care

15. Safety & Handling