#DEN4001
#D4/S1/W3
#Paediatrics

Treatment options under GA

• aim at ensuring all treatment required is done under single GA
• caries risk assessment is critical
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Caries relapse

• soon after general anaesthetic, many children develop more decay and need additional extensive treatment, and in many cases, a second GA
• repeat GA due to
  • failures in treatment planning process
  • failure in adoption of preventive counselling which should be given as part of an episode of GA treatment planning
• repeat GA undesirable in terms of
  • morbidity
  • potential mortality
  • cost
  • behavioural emotional effects on child

RESTORATIVE TREATMENT UNDER GA

• needs to be long lasting in order to manage disease, and prevent need for more treatment / GA
• primary tooth restored under GA should be expected to exfoliate naturally without failure
• consider
• patient age
  • is tooth permanent or deciduous
  • how long does the tooth need to be maintained in the mouth
• extent of caries
  • depth and spread of carious lesion will guide our restorative options
  • is pulp therapy needed
  • consider amount and quality of remaining dentine and enamel and how restorative material of choice will interact with this
  • e.g. enough viable enamel to bond to if using composite resin
• assessment of potential OH maintenance
  • make assessment of patient and guardians adherence and willingness to maintain good OH
  • poor oral hygiene may necessitate differing choices
• BASICALLY
  • more predictably successful restorations should be provided
  • treatment plans should aggressively resolve the presenting complaint
  • treatment alternatives must provide predictable outcomes
  • heroic but unrealistic treatment should not be undertaken
  • deciduous pulpectomies should not be considered
  • teeth with doubtful prognoses should be extracted

SSC

• relatively inexpensive
• offer advantage of full coronal coverage
• most durable restorations for primary dentition with survival times greater than 40 months
• preferred restoration following pulpotomies
• convention SSC is restoration of choice for primary molars under GA
  • for high caries mouth
  • 2+ surface involvement
  • tooth exfoliation >3 years
  • poor parent compliance and lack of possibility of a long term follow up is possible
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Other restorative options

• amalgam, composite or GIC should be reserved for one or two surface restorations in primary molars where expected exfoliation of the tooth is within 3 years
• temporary/provisional may be indicated in circumstances where exfoliation is imminent
• rubber dam mandatory for all endodontic procedures

Preventative treatment under GA

home care fluoride products

fluoride toothpaste

• 500ppm - 5000ppm
• usually sodium fluoride NaF or sodium monofluorophosphate MFP
• NaF considered to be more effective in caries reduction due to rapid dissociation properties, enhances bioavailability of fluoride ions for optimal dental protection
• for children
  • supervision for toothbrushing until about 9
  • small amount of toothpaste
  • swish and spit rather than swallow
• neutrafluor for those over age of 12 and high caries risk
• stannous fluoride toothpaste (Colgate Gel Kam or Sensodyne Rapid Relief) for those with hypersensitivity or for antibacterial effects, however not for long term use due to potential for staining
• fluoride mouth rinse (neutrafluor 220 and 990) for adjunct protection
  • colgate neutrafluor 220, 0.05% NaF, over the counter low fluoride concentration for daily use
  • colgate neutrafluor 990, 0.2% NaF, usually weekly rinse in school based programs or daily for high risk caries
  • fluoroide mouth rinse reserved for patients onlder than 6 years and at higher risk
  • rinse 60 seconds 10ml twice per day after brushing or flossing, dont rinse with water immediately after

Professional fluoride application

• higher concentration, low frequency of application
• booster to supplement home care products, enhance overall effectiveness of a patients oral hygiene routine
• gel
  • not for under 10 years, to prevent ingestion
  • neutral fluoride gel is product of choice
  • some concerns associated with acidulated phosphate fluoride APF (can etch porcelain), also very sour, very low pH (dont administer if infection)
• varnish
  • potential to remin teeth and address sensitivity or exposed root/neck
  • fluor protector (ivoclar/vivadent), duraphat, premier enamelpro varnish
• tooth mousse plus
  • fluoride containing topical product
  • active ingrediant NaF 900ppm and CPP-ACP (casein phosphopeptide0amorphous calcium phosphate), which binds calcium and phosphate delivering them to tooth in soluble form
  • contraindicated for milk protein allergies but suitable for lactose intolerance
  • provide F, Ca, P to oral environment
  • indicated for white spot lesions, high caries risk patients, desensitising sensitive teeth, dry mouth, patients with acidic oral environment, morning sickness during pregnancy, during and/or after ortho treatment, following teeth whitening
  • not for children under 6 years due to fluoride concentration, version without fluoride can be used for children under 6

Responsibility of referring clinician

• responsibility of practitioner to reduce need for repeat GA, demands more radical and appropriate treatment planning, identification of patients who are high caries risk, and have cooperation problems
  • need to be involved in intensive prevention programme
• pattern of attendance after GA is significant in risk of a repeat GA, proactive approach towards preventive care needed to reduce development of new dental disease
  • responsibility of referring clinician to facilitate regular review and for on going prevention
• key factors to reduce number of children receiving GA
  • early identificaiton of high caries risk
  • intensive preventive care
  • behaviour management techniques
• post GA review visit important to
  • influence positive change in parents health behaviour that will be effective in controlling caries and caries relapse
  • influence childs acceptance of dental treatment at follow up
  • reduce need for repeat GA

ACSC/PPH

• ambulatory care sensitive conditions / potentially preventable hospital admission
• conditions for which hospitalisation is thought to be avoidable with the application of
  • public interventions and
  • early disease management
• which are usually delivered in an ambulatory setting such as primary care
• high rates of hospital admissions for ACSC may provide indirect evidence of
  • inadequate public health programs
  • problems with patient access to primary health care
  • inadequate skills and resource or
  • disconnection with specialist services

Responsibility of the guardian

importance of engaging guardian

• young children do not hold development capacity to make critical decisions themselves
• need to influence guardians to change behaviour and actions of a child

Transtheoretical stages of change model (prochaska and Velicer)

• health behaviour change involves progress through six stages
• precontemplation
  • not intending to take action in forseeable future
  • usually uninformed or underinformed about consequences
  • may have attempted to change and have become demoralisedabout ability to change
  • resistant/unmotivated
• contemplation
  • intending to change within 6 months
  • more aware of pros but acutely aware of cons
• preparation
  • intending to take action in immediate future (like next month)
  • have taken some significant action in the past year
• action
  • have made specific overt modifications in their life styles within the past 6 months,
• maintenance
  • working to prevent relapse but dont apply change processes as frequently as people in action, less tempted to relapse and more confident to continue changes
• people can come in and out of cyclical model at any point
• need to identify position in the model and develop stage appropriate intervention strategies and techniques
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Parenting styles

Authoritarian parenting

• tendency to have one way mode of communication, parent establish rules which child obeys
• little explanation of rules, expects child to follow them without negotiation or error
• mistakes usually lead to punishment
• lack of nurturing and have high expectations with limited flexibility
• may result in children with higher levels of aggression or shy and socially inept with poor self esteem

Authoritative parenting

• close nurturing relationship with children that requires a lot of patience and effort on both parties
• disciplinary methods are used as a way of support instead of punishment
• frequent and appropriate levels of communication between parent and their child about clear guidelines for their expectations and explanation for reasons associated with disciplinary actions
• leads to healthiest outcomes for children with children becoming confident, responsible, able to self regulate, high level of academic achievement and school performance

Permissive parenting

• warm, nurturing and usually have minimal or no expectations
• limited rules which tends to lead to children with unhealthy eating habits, snacking and therefore increased risks for obesity and other health problems later in the child's life
• open communication but little guidance from parents, parents allow their children to figure things out for themselves

Uninvolved parenting

• children given a lot of freedom
• parent fulfill child's basic needs but remain detached from their life
• no particular discipline style
• limited amount of communication and little nurturing for and with child

POST GA OUTCOMES AMIN AND HARRISON 2007

• relapse vs no relapse
• GA had no effect on their co operational level
• no relapse group
  • GA was a wake up for themselves
  • new awareness of early dental visits and regular check ups
• relapse group
  • valued baby teeth less than no relapse group
  • perceived child to be less susceptible after GA
  • thought that their child would be more attentive to dental health after GA
  • lower self efficacy for controlling childs oral health
  • earlier stages or changes
  • less receptive to advice from others
  • more permissive regarding childs desires
  • no immediate plans to change home care behaviours

Post GA review

• GA is not a fix all approach
• patient and family need to be actively engaged in maintaining oral health of the child
• GA will not prevent recurrence of disease and need to involve families of children to prevent relapse
• Parent centred counseling
  • brief counselling rather than lecture
  • motivational interviewing to examine and resolve feelings about preventive practices and avoids complicated advice
• influence child acceptance of dental treatment at follow up appointments
  • reduce uncertainty and acclimatise to dental care
  • modelling
  • cognitive approach
    • dealing with negative thoughts
    • distractions
  • relaxation
  • systematic desensitisation

Possible strategies

• radical treatment during GA
  • SSC for multisurface and pulp treated
  • prophylactic SSC restorations
  • pulpotomies vs indirect pulp caps
  • extractions vs pulpectomies
  • individualised recall system
  • caries risk assessment
  • optimum clinical techniques
  • hall crown
  • health promotion
  • preventative
    • diet counselling/discussion
    • OHI
    • fluoride
    • tooth mousse
    • FS
  • inhalation sedation techniques

Brief motivational interviewing

• 30s - 5min
• leave interaction feeling good and inspired
• 2 way interaction that gets person to talk
• open questioning and listening effectively
• affirmations, reflective listening
• summary at end