The Reference Manual of Pediatric Dentistry 2020-2021

The
Reference Manual
of Pediatric Dentistry
Definitions
Oral health policies
Recommendations
Endorsements
Resources
2020– 2021
®
®
© 2020 American Academy of Pediatric Dentistry
211 East Chicago Avenue, Suite 1600

Chicago, Illinois, 60611
ISBN 978-1-7334978-2-4 (print)
All rights reserved. No part of this manual may be reproduced in any form or by any means, including
photocopying, or utilized by any information storage and retrieval system without written permission
from the American Academy of Pediatric Dentistry. Copyright release request can be forwarded to the
attention of Chief Executive Office Dr. John S. Rutkauskas, American Academy of Pediatric Dentistry,
211 East Chicago Avenue, Suite 1600, Chicago, Illinois 60611.
Suggested citation (except for Clinical Practice Guidelines and Endorsements — follow the ‘How to Cite’
instructions specified in each document)
American Academy of Pediatric Dentistry. Caries-risk assessment and management for infants, children,
and adolescents. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2020:243-7.
To purchase additional copies of this book, visit the American Academy of Pediatric Dentistry Store at
https://store.aapd.org/.
American Academy of Pediatric Dentistry
Members & Consultants of the Councils on Clinical Affairs & Scientific Affairs *
Soraya M. Beiraghi Gajanan V. Kulkarni

Enrique Bimstein Naomi Lane
Sheila Marie Brown Randall K. Lout
Jeffrey N. Brownstein Oariona Lowe
Erin Ealba Bumann Man Wai Ng
Ann M. Bynum Anne C. O’Connell
Erica M. Caffrey Mitali Y. Patel
James C. Cannava Kimberly Kay Patterson
Natalia Chalmers Rocio Quiñonez
Jung-Wei Anna Chen Francisco J. Ramos-Gomez
Donald L. Chi Hans C. Reinemer
Judith R. Chin Edward L. Rick
Carolyn B. Crowell R. Glenn Rosivack
Yasmi O. Crystal Brian J. Sanders
Jennifer L. Cully Allison Scully
Vineet Dhar Rachael L. Simon
Kimon Divaris Julio E. Sotillo
Maria Regina ( Ninna ) P. Estrella Thomas R. Stark
Scott Goodman William V. Stenberg †
Elizabeth Gosnell Jenny Ison Stigers
Jennifer Hill Norman Tinanoff
Shijia Hu Kaaren Vargas
Rishita A. Jaju Karin Weber-Gasparoni
Elva V. Jordan Anne R. Wilson
Carolyn A. Kerins J. Timothy Wright
* As of May 2020. The oral health policies and best practices of the
AAPD are developed under the direction of the Board of Trustees,
utilizing the resources and expertise of its membership operating
through the Council on Clinical Affairs. The Council on Scientific
Affairs provides input as to the scientific validity of a policy or
recommendation.
† External consultant / Periodontist, Texas A&M University, Dallas,
Texas.
Table of Contents
Introduction
7 Overview
10 Strategic Plan
Revised 12 Research Agenda
Definitions
15 Dental Home
Reaffirmed 16 Dental Neglect
17 Dental Disability
18 Medically-Necessary Care
Reaffirmed 19 Special Health Care Needs
Oral Health Policies

22 Medically-Necessary Care
28 Social Determinants of Children’s Oral Health and Health Disparities
New 32 Care for Vulnerable Populations in a Dental Setting
Revised 39 Oral Health Care Programs for Infants, Children, Adolescents, and Individuals with Special Health Care Needs
43 Dental Home
45 Workforce Issues and Delivery of Oral Health Care Services in a Dental Home
51 Child Identification Programs
Reaffirmed 53 Oral Health in Child Care Centers
56 Mandatory School-Entrance Oral Health Examinations
59 School Absences for Dental Appointments
61 Emergency Oral Care for Infants, Children, Adolescents, and Individuals with Special Health Care Needs
62 Role of Dental Prophylaxis in Pediatric Dentistry
64 Use of Fluoride
66 Use of Silver Diamine Fluoride for Pediatric Dental Patients
Revised 70 Use of Xylitol in Pediatric Dentistry
72 Interim Therapeutic Restorations (ITR)
74 Management of the Frenulum in Pediatric Dental Patients
79 Early Childhood Caries (ECC): Classifications, Consequences, and Preventive Strategies
82 Early Childhood Caries (ECC): Unique Challenges and Treatment Options
84 Dietary Recommendations for Infants, Children, and Adolescents
87 Snacks and Beverages Sold in Schools
Revised 89 Tobacco Use
Revised 94 Electronic Nicotine Delivery Systems (ENDS)
98 Substance Abuse in Adolescent Patients
Revised 102 Human Papilloma Virus Vaccinations
104 Intraoral/Perioral Piercing and Oral Jewelry/Accessories
106 Prevention of Sports-Related Orofacial Injuries
112 Use of Dental Bleaching for Child and Adolescent Patients
116 Use of Lasers for Pediatric Dental Patients
119 Obstructive Sleep Apnea (OSA)
122 Acute Pediatric Dental Pain Management
125 Minimizing Occupational Health Hazards Associated with Nitrous Oxide
Revised 127 Hospitalization and Operating Room Access for Oral Care of Infants, Children, Adolescents, and Individuals with Special Health Care Needs
Revised 129 Hospital Staff Membership
131 Model Dental Benefits for Infants, Children, Adolescents, and Individuals with Special Health Care Needs
135 Third-party Reimbursement for Management of Patients with Special Health Care Needs
138 Third-party Reimbursement of Medical Fees Related to Sedation/General Anesthesia for Delivery of Oral Health Care Services
141 Third-party Reimbursement for Oral Health Care Services Related to Congenital and Acquired Orofacial Anomalies
143 Third-party Reimbursement of Fees Related to Dental Sealants
145 Third-party Fee Capping of Non-Covered Services
147 Third-party Payor Audits, Abuse, and Fraud
151 Role of Pediatric Dentists as Both Primary and Specialty Care Providers
152 Transitioning from a Pediatric-Centered to an Adult-Centered Dental Home for Individuals with Special Health Care Needs
156 Patient Safety
160 Selecting Anesthesia Providers for the Delivery of Office-Based Deep Sedation/General Anesthesia
Revised 163 Ethical Responsibilities in the Oral Health Care Management of Infants, Children, Adolescents, and Individuals with Special Health Care Needs
165 Patient’s Bill of Rights and Responsibilities
167 Using Harvested Dental Stem Cells
Revised 169 Infection Control
4 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

INTRODUCTION: OVERVIEW
Recommendations
Clinical Practice Guidelines
174 Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those with Special Health Care Needs
184 Use of Pit-and-Fissure Sealants
201 Use of Vital Pulp Therapies in Primary Teeth with Deep Caries Lesions
New 215 Use of Non-Vital Pulp Therapies in Primary Teeth
Best Practices
232 Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children,
and Adolescents
243 Caries-Risk Assessment and Management for Infants, Children, and Adolescents
248 Prescribing Dental Radiographs for Infants, Children, Adolescents, and Individuals with Special Health Care Needs
252 Perinatal and Infant Oral Health Care
Revised 257 Adolescent Oral Health Care
267 Oral Health Care for the Pregnant Adolescent
275 Management of Dental Patients with Special Health Care Needs
281 Oral and Dental Aspects of Child Abuse and Neglect
288 Fluoride Therapy
Revised 292 Behavior Guidance for the Pediatric Dental Patient
Revised 311 Use of Protective Stabilization for Pediatric Dental Patients
Revised 318 Use of Local Anesthesia for Pediatric Dental Patients
324 Use of Nitrous Oxide for Pediatric Dental Patients
330 Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures
358 Use of Anesthesia Providers in the Administration of Office-Based Deep Sedation/General Anesthesia to the Pediatric Dental Patient
362 Pain Management in Infants, Children, Adolescents, and Individuals with Special Health Care Needs
371 Pediatric Restorative Dentistry
Revised 384 Pulp Therapy for Primary and Immature Permanent Teeth
393 Management of the Developing Dentition and Occlusion in Pediatric Dentistry
410 Acquired Temporomandibular Disorders in Infants, Children, and Adolescents
418 Classification of Periodontal Diseases in Infants, Children, Adolescents, and Individuals with Special Health Care Needs
Revised 433 Management Considerations for Pediatric Oral Surgery and Oral Pathology
443 Use of Antibiotic Therapy for Pediatric Dental Patients
447 Antibiotic Prophylaxis for Dental Patients at Risk for Infection
453 Dental Management of Pediatric Patients Receiving Immunosuppressive Therapy and/or Radiation Therapy
462 Record-keeping
470 Informed Consent
Endorsements
New 476 International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: General Introduction
Revised 481 International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: 1. Fractures and Luxations
Revised 497 International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: 2. Avulsion of Permanent Teeth
Revised 506 International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: 3. Injuries in the Primary Dentition
521 Policy on the Management of Patients with Cleft Lip/Palate and Other Craniofacial Anomalies
523 Periodontal Diseases of Children and Adolescents
532 Guidelines for Periodontal Therapy
537 Treatment of Plaque-Induced Gingivitis, Chronic Periodontitis, and Other Clinical Conditions
547 Healthy Beverage Consumption in Early Childhood: Recommendations from Key National Health and Nutrition Organizations: Summary
of Oral Health Considerations
Resources
553 Dental Growth and Development
554 Growth Charts
560 Body Mass Index (BMI) Charts
562 Recommended USDA Food Patterns
Revised 565 Childhood and Adolescent Immunization Schedule
573 Speech and Language Milestones
575 Pediatric Medical History
578 Chairside Guide: Silver Diamine Fluoride in the Management of Dental Caries Lesions
Revised 580 Acute Traumatic Injuries: Assessment and Documentation
Revised 582 Acute Management of an Avulsed Permanent Tooth
Revised 584 Preparing for Your Child’s Sedation Visit
Revised 586 Sedation Record
588 Post-Operative Instructions for Extractions/Oral Surgery
589 Record Transfer
590 Release for School Absences
591 Common Laboratory Values
Revised 592 Useful Medications for Oral Conditions
New 599 Severe Acute Respiratory Syndrome Coronavirus 2 Transmission
600 Management of Medical Emergencies
Revised 602 Basic Life Support /Cardiopulmonary Resuscitation
603 Delineation of Privileges
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 5

Introduction
Overview
Strategic Plan
Research Agenda
Overview How to Cite: American Academy of Pediatric Dentistry. Overview.

The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2020:7-9.
Definitions and scope of pediatric dentistry Intent of The Reference Manual of Pediatric
Pediatric dentistry is an age-defined specialty that provides Dentistry
both primary and comprehensive preventive and therapeutic The Reference Manual of Pediatric Dentistry is intended to en-
oral health care for infants and children through adolescence, courage a diverse audience to provide the highest possible level
including those with special health care needs.1 of care to children. This audience includes, but is not limited to:
To become a pediatric dental specialist, a dentist must • pediatric dentists.
satisfactorily complete a minimum of 24 months in an ad- • general dental practitioners and other dental specialists.
vanced education program accredited by the Commission on • physicians and other health care providers.
Dental Accreditation of the American Dental Association. • government agencies and health care policy makers.
Such programs “must be designed to provide special knowl- • individuals interested in the oral health of children.
edge and skills beyond the DDS or DMD training...”1 The
curriculum of an advanced program provides the dentist with The Reference Manual of Pediatric Dentistry is divided into
necessary didactic background and clinical experiences to pro- five sections: (1) Definitions, (2) Oral Health Policies, (3)
vide comprehensive primary oral health care and the services Recommendations, (4) Endorsements, and (5) Resources. Oral
of a specialist. Pediatric dentists provide care, conduct health policies are statements relating to AAPD positions on
research, and teach in a variety of clinical and institutional various public health issues. Recommendations are developed
settings, including private practice and public health. They to assist the dental provider in making decisions concerning
work in coordination with other health care providers and patient care. This section has two subcategories, Clinical
members of social disciplines for the benefit of children. Practice Guidelines and Best Practices, distinguished by the
The primary focus of most dental specialties is a particular methodology employed to develop the recommendations. Ad-
area of dental, oral, or maxillofacial expertise. Pediatric dentist- herence to the recommendations increases the probability of
ry encompasses a variety of disciplines, techniques, procedures, a favorable practice outcome and decreases the likelihood of
and skills that share a common basis with other specialties, an unfavorable practice outcome. The endorsements section
but are modified and adapted to the unique requirements of includes clinical recommendations relevant to the practice of
infants, children, adolescents, and those with special health pediatric dentistry that have been developed by organizations
care needs. By being an age-specific specialty, pediatric dentist- with recognized expertise and adopted by the AAPD.
ry encompasses disciplines such as behavior guidance, care of Resources contains supplemental information to be used as
the medically and developmentally compromised and disabled a quick reference when more detailed information is not
patient, supervision of orofacial growth and development, readily accessible, as well as clinical forms offered to facilitate
caries prevention, sedation, pharmacological management, excellence in practice.
and hospital dentistry, as well as other traditional fields Proper utilization of The Reference Manual of Pediatric
of dentistry. These skills are applied to the needs of children Dentistry necessitates recognizing the distinction between
throughout their ever-changing stages of development and to standards and recommendations. Although there are certain
treating conditions and diseases unique to growing individuals. instances within the recommendations where a specific action
The American Academy of Pediatric Dentistry (AAPD), is mandatory, The Reference Manual of Pediatric Dentistry is
founded in 1947, is the membership organization representing not intended nor should it be construed to be either a stan-
the specialty of pediatric dentistry. Its members put children dard of care or a scope of practice document. The Reference
first in everything they do, and at the highest standards of Manual of Pediatric Dentistry contains recommendations for
ethics and patient safety. They provide care to millions of care that could be modified to fit individual patient needs
our nation’s infants, children, adolescents, and persons with based on the patient, the practitioner, the health care setting,
special health care needs, and are the primary contributors to and other factors.
professional education programs and publications on pediatric
oral health. Definitions
The AAPD, in accordance with its vision and mission, For the purpose of this document, the following definitions
advocates optimal oral health for all children. It is the leading shall apply:
national advocate dedicated exclusively to children’s oral Standards: Any definite rule, principle, or measure established
health. Advocacy activities take place within the broader by authority. Standards say what must be done. They are
health care community and with the public at local, regional, intended to be applied rigidly and carry the expectation that
and national levels. The Reference Manual of Pediatric Dentistry they are applied in all cases and any deviation from them
is one of the components of the Academy’s advocacy activities. would be difficult to justify. The courts define legal standards
of care.

Clinical practice guidelines (CPG): “statements that include of the AAPD Pediatric Oral Health Research and Policy
recommendations intended to optimize patient care. They Center. CCA and CSA are composed of individuals repre-
are informed by a systematic review of evidence and an senting the five geographical (trustee) districts of the AAPD,
assessment of the benefits and harms of alternative care along with additional consultants confirmed by the BOT.
options.”2 The EBDC is comprised of two members from each of these
CPG are intended to be more flexible than standards. They councils as well as the AAPD’s editor-in-chief. Council/
should be followed in most cases, but they recognize that committee members and consultants derive no financial
treatment can and should be tailored to fit individual needs, compensation from the AAPD for their participation in
depending on the patient, practitioner, setting, and other development of oral health policies, best practices, and
factors. Deviations could be fairly common and could be clinical practice guidelines, and they are asked to disclose
justified by differences in individual circumstances. CPG potential conflicts of interest. The AAPD has neither solicited
originate in an organization with recognized professional ex- nor accepted any commercial involvement in the development
pertise and stature. They are designed to produce optimal of the content of this publication.
outcomes, not minimal standards of practice. Proposals to develop or modify oral health policies and
best practices may originate from four sources:
Best practices: “the best clinical or administrative practice or • the officers or trustees acting at any meeting of the
approach at the moment, given the situation, the consumer’s BOT.
or community’s needs and desires, the evidence about what • a council, committee, or task force in its report to
works for this situation/need/desire, and the resources the BOT.
available.”3 Like CPG, best practices are more flexible than • any member of the AAPD who submits a written
standards and originate in an organization with recognized request to the BOT as per the AAPD Administrative
professional expertise and stature. Although they may be un- Policy and Procedure Manual, Section 9 (the full
solicited, they usually are developed following a stated request text of this manual is available on the Members’ Only
or perceived need for clinical advice or instruction. page of the AAPD website).
• officers, trustees, council and committee chairs, or
Must or shall: Indicates an imperative need and/or duty; an other participants at the AAPD’s Annual Strategic
essential or indispensable item; mandatory. Planning Session.
Should: Indicates the recommended need and/or duty; highly Regardless of the source, proposals for oral health policies
desirable. and best practices are considered carefully, and those deemed
sufficiently meritorious by a majority vote of the BOT are
May or could: Indicates freedom or liberty to follow a sug- referred to the CCA for development or review/revision. The
gested alternative. CCA members are instructed to follow the specified process
and format for the development of a policy. Oral health
Parent: Unless otherwise indicated, the term parent as used policies and best practices utilize two sources of evidence:
in these oral health policies and recommendations has a the scientific literature and experts in the field. The CCA, in
broad meaning encompassing a natural/biological or adoptive collaboration with the CSA, performs a literature review for
father or mother of a child with full parental legal rights, a each document. When scientific data do not appear conclusive
person recognized by state statute to have full parental legal or supplemental expertise is deemed beneficial, authorities
rights, a parent who in the case of divorce has been awarded from other organizations or institutions may be consulted.
legal custody of a child, a person appointed by a court to be The CCA meets on an interim basis to discuss proposed
the legal guardian of a minor child, or a foster parent (a non- oral health policies and best practices. Each new or reviewed/
custodial parent caring for a child without parental support revised document is deliberated, amended if necessary, and
or protection who was placed by local welfare services or a confirmed by the entire council. Once developed by the
court order). CCA, the proposed document is submitted for the consider-
ation of the BOT. While the Board may request revision, in
Development of oral health policies, best practices, and which case it is returned to the council for modification,
clinical practice guidelines once accepted by majority vote of the Board, it is referred
The oral health policies, best practices, and clinical practice for Reference Committee hearing at the next Annual
guidelines of the AAPD are developed under the direction Session. The Reference Committee Hearing is an open forum
of the Board of Trustees (BOT), utilizing the resources and for the membership to provide comment or suggestion for
expertise of its membership operating through the Council alteration of the document. The CCA carefully considers all
on Clinical Affairs (CCA), the Council on Scientific Affairs remarks presented at the Reference Committee Hearing prior
(CSA), and the Evidence-based Dentistry Committee (EBDC) to submitting its final document for ratification by a majority

vote of the membership present and voting at the General Review of oral health policies and clinical
Assembly. If accepted by the General Assembly, either as recommendations
proposed or as amended by that body, the document then Each AAPD oral health policy, best practice, and clinical
becomes the official AAPD oral health policy or best practice practice guideline is reviewed for accuracy, relevance, and
for publication in The Reference Manual of Pediatric currency no less than once every five years, and more often if
Dentistry and on the AAPD’s website (http://www.aapd.org/ directed by the BOT. After completing a new literature
Policies/). search, reviewers may recommend reaffirmation, revision, or
The EBDC provides oversight and management of the retirement of the document. Policies and recommendations
CPG development process. The topic for each guideline is of other organizations that have been endorsed by the AAPD
recommended by the EBDC and approved by the BOT. are reviewed annually to determine currency as well as appro-
Once a topic has been affirmed, the process begins with priateness for the AAPD’s continued endorsement.
searches for an existing CPG from another organization with
recognized expertise and for related systematic reviews. The References
EBDC will evaluate available publications and recommend 1. American Dental Association Commission on Dental
either endorsement of an existing guideline or development Accreditation. Accreditation standards for advanced spe-
of a new CPG. If a CPG is to be developed, the EBDC cialty education programs in pediatric dentistry. Chicago,
recommends to the BOT individuals for the guideline work- Ill.; 2018. Available at: “https://www.ada.org/~/media/
group. Workgroup members are respected clinicians (end CODA/Files/ped.pdf?la=en”. Accessed August 19, 2017.
users), authors of peer reviewed publications in the topic under ®
(Archived by WebCite at: “http://www.webcitation.
review, and methodology experts. All workgroup members org/6tmIjYfqt”)
should be capable of knowledgeably assessing a body of 2. Institute of Medicine. Introduction. In: Clinical Practice
evidence using criteria approved by the EBDC. The duties of Guidelines We Can Trust. 2011. Washington, D.C.: The
each workgroup may include: National Academies Press. doi: 10.17226/13058. Avail-
• develop a research protocol. able at: “https://www.nap.edu/read/13058/chapter/3#25”.
• develop the PICO (Patient, Intervention, Comparison, Accessed August 19, 2017. (Archived by WebCite at: ®
Outcome) question for each guideline. “http://www.webcitation.org/6tmIpMB43”)
• select studies for full-text retrieval and extraction, and 3. Centers for Disease Control and Prevention. Acronyms,
extract for each study selected. glossary, and reference terms. Available at: “https://www.
• perform evidence synthesis: meta-analysis or narrative cdc.gov/nphpsp/PDF/Glossary.pdf ”. Accessed August 19,
synthesis. ®
2017. (Archived by WebCite at: “http://www.webcitation.
• grade evidence (based on GRADE criteria4). org/6tmJ1MMBP”)
• write a systematic review. 4. Schünemann H, Brożek J, Guyatt G, Oxman A. GRADE
• review and edit a guideline. Handbook: Handbook for grading the quality of evidence
• modify a guideline according to external review recom- and the strength of recommendations using the GRADE
mendations. approach. Update October 2013. The GRADE Working
Group. Available at: “http://gdt.guidelinedevelopment.org
AAPD may choose to develop CPG in collaboration with /app/handbook/handbook.html”. Accessed July 10, 2017.
other organizations of recognized expertise and stature. Such ®
(Archived in WebCite at: “http://www.webcitation.org/
joint guidelines would undergo a similar development process 6tVAxOrq2”)
and be based on a systematic review of the evidence.
Each proposed CPG is circulated to the CCA, CSA, and
BOT for review and comment prior to submission for publi-
cation. These documents, however, do not undergo ratification
by the General Assembly. Rather, once finalized by the EBDC,
the document becomes an official CPG of the AAPD for
publication in Pediatric Dentistry, reprinting in The Reference
Manual of Pediatric Dentistry, and posting on the AAPD’s
website (http://www.aapd.org/Policies/).

INTRODUCTION: STRATEGIC PLAN
The American Academy of Pediatric Dentistry

Strategic Plan 2020
Adopted How to Cite: American Academy of Pediatric Dentistry. The American
Academy of Pediatric Dentistry strategic plan 2020. The Reference
2017 Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2020:10-1.
Vision • Support and promote programs that provide care to

Optimal oral health for all children. those in need.
Mission Workforce and Practice Transformation

To advance optimal oral health for all children by deliver- We support the pediatric dental workforce, expanding its
ing outstanding service that meets and exceeds the needs and reach and to better address children’s oral health needs. We
expectations of our members, partners, and stakeholders. develop practical tools and resources to help all members in
any practice setting build and sustain high-functioning dental
AAPD Culture care practices to the benefit of their patients and their com-
Our members put children first in everything they do, and at munities.
the highest standards of ethics and patient safety. As such, • Support research to examine the distribution and pro-
the American Academy of Pediatric Dentistry is THE leading files of providers, to help members make informed
national advocate dedicated exclusively to children’s oral decisions about their practices.
health. We are the embodiment of our members’ expertise as • Develop and provide tools that enable our members
the big authorities on little teeth. in all practice settings to provide optimal care.
• Offer education courses in non-clinical areas of dental
Strategic Objectives practice.
Clinical Expertise • Assist members in achieving a healthy work-life bal-
We equip our members and all other providers with data, ance so they can enjoy a sustained career in pediatric
knowledge, competencies, and skills to provide safe, high- dentistry.
quality, evidence-based patient care in the context of a dental • Provide opportunities to develop leadership skills that
home. will help our members in their practice as well as in
• Provide and promote continuing clinical education that volunteer positions in the AAPD.
meets the changing needs of patients and their care- • Sponsor programs to manage student debt.
givers.
• Use the authority and expertise of our members to Advocacy
advocate for patient safety, improved outcomes, and We take a solutions-based approach to educating the broader
intelligent regulatory oversight. dental profession, local, state, and national policy makers, and
• Invest in pre- and post-doctoral education by support- consumers/parents about critical issues affecting child oral
ing training programs, advising accreditation boards, health in the United States.
and sponsoring programs to enhance success through- • Advise and influence public policy through direct ad-
out their career. vocacy as well as by training members to be advocates
in their practices and their communities.
Patient Care and Access • Educate the public on key children’s oral health topics
We help members address barriers to care, such as parent oral through public service messages, media interviews by
health literacy and affordability; reduce administrative burdens AAPD-trained spokespersons, contributions to parent
for payment/reimbursement; and invest in community-based blogs, and other communication opportunities as they
initiatives providing care to underserved children. occur.
• Support research that identifies the scope of dental need • Help members to exchange information on legislative
in the U.S. and supports the best clinical practices for issues.
patient care. • Exchange information with other healthcare and chil-
• Advocate for legislative reforms to reduce the admin- dren’s organizations.
istrative complexity of reimbursement for dental
treatment.

INTRODUCTION: STRATEGIC PLAN
Operations • Help volunteer leadership concentrate on issues by

We maintain organizational effectiveness by meeting and providing full administrative support and strategic
exceeding accepted professional association management advice.
standards. • Coordinate marketing and public relations for a con-
• Nurture an efficient and effective governance struc- sistent message to members and the public.
ture that incorporates a variety of experiences so that • Select and develop the best talent.
all viewpoints are represented. The structure creates a • Provide solid financial analysis and direction for all
network of experts so that AAPD can quickly respond activities of the AAPD.
to emerging issues.

INTRODUCTION: RESEARCH AGENDA
The American Academy of Pediatric Dentistry

Research Agenda
Revised How to Cite: American Academy of Pediatric Dentistry. The American
Academy of Pediatric Dentistry research agenda. The Reference Manual
2020 of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Dentistry; 2020:12.
The American Academy of Pediatric Dentistry (AAPD) • Translational research: Moving scientific knowledge into
recognizes that high-quality evidence is the foundation of the practice and policy (e.g., dissemination and implementa-
science and practice of pediatric dentistry. Clinical care should tion of evidence-based care principles into clinical practice,
be based on evidence-based dentistry (EBD) principles. Where barriers to dissemination and implementation, policy and
there is insufficient evidence, relevant research should be practice partnerships).
conducted to help fill scientific gaps and better inform clinical • Health and safety research: Increasing our understanding
practice. The AAPD Council on Scientific Affairs is charged of protection from COVID-19 and other transmittable
with updating and affirming the AAPD Research Agenda. diseases in the oral care setting (e.g., infection control,
The AAPD Research Agenda highlights strategic research personal protective equipment, waterline disinfection,
topics relevant to the practice of pediatric dentistry. To help sterilization techniques, interdisciplinary care teams, and
improve individual patient and population oral health outcomes, telehealth/teledentistry).
we urge academic, state, federal, philanthropic, and corporate
funding agencies to devote resources to the following areas:
• Clinical research: Improving diagnosis, prevention, and
management of dental and craniofacial conditions (e.g.,
emerging dental caries management agents, precision/
personalized oral health care, technologies and strategies
to monitor and promote health and self-care).
• Interdisciplinary research: Understanding and eliminating
oral health disparities to promote oral health (e.g., basic
behavioral and social determinants of health, basic science
of craniofacial development, applied microbiology and
microbiome research, development of evidence-based
public health interventions, clinical trials focusing on chil-
dren and vulnerable populations, integration of dentistry
into the broader health care delivery system, bioinformatics,
quality of care, models of interprofessional collaboration,
data sharing and training, and team science).

DEFINITIONS: DENTAL NEGLECT
Definitions
Dental Home
Dental Neglect
Dental Disability
Medically-Necessary Care
Special Health Care Needs

DEFINITIONS: DENTAL HOME
Definition of Dental Home

Latest Revision
2018 How to Cite: American Academy of Pediatric Dentistry. Definition of
dental home. The Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2020:15.
The dental home is the ongoing relationship between the dental home addresses anticipatory guidance and preventive,
dentist and the patient, inclusive of all aspects of oral health acute, and comprehensive oral health care and includes referral
care delivered in a comprehensive, continuously accessible, co- to dental specialists when appropriate.
ordinated, and family-centered way. The dental home should This definition was developed by the Council on Clinical
be established no later than 12 months of age to help children Affairs and adopted in 2006. This document is an update of
and their families institute a lifetime of good oral health. A the previous version, revised in 2015.

DEFINITIONS: DENTAL NEGLECT
Definition of Dental Neglect

Latest Reaffirmation
dental neglect. The Reference Manual of Pediatric Dentistry. Chicago,
Dental caries, periodontal diseases, and other oral conditions, Dental neglect is willful failure of parent or guardian to
if left untreated, can lead to pain, infection, and loss of func- seek and follow through with treatment necessary to ensure
tion. These undesirable outcomes can adversely affect learning, a level of oral heath essential for adequate function and
communication, nutrition, and other activities necessary for freedom from pain and infection.
normal growth and development. This definition was developed by the Child Abuse Sub-
committee of the Clinical Affairs Committee and adopted in
1983. This is the sixth reaffirmation of the 1992 version.

DEFINITIONS: DENTAL DISABILITY
Definition of Dental Disability

Latest Revision
dental disability. The Reference Manual of Pediatric Dentistry. Chicago,
Dental caries, periodontal disease, dentoalveolar trauma, and intake, growth and development, or participation in life
other pathological orofacial conditions, left untreated, can activities.
limit substantially an individual’s development and quality This definition was developed by the Child Abuse Sub-
of life. Therefore, an individual should be considered to have committee of the Clinical Affairs Committee and adopted
a dental disability if orofacial pain, infection, or pathological in 1983. This document is an update of the previous version,
condition and/or lack of functional dentition affect nutritional revised in 2012.

DEFINITIONS: MEDICALLY-NECESSARY
DENTAL NEGLECT CARE
Definition of Medically-Necessary Care

Reaffirmation How to Cite: American Academy of Pediatric Dentistry. Definition of
2019 medically-necessary care. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:18.
Medically-necessary care (MNC) is the reasonable and essen- MNC must take into account the patient’s age, developmental
tial diagnostic, preventive, and treatment services (including status, and psychosocial well-being, in addition to the setting
supplies, appliances, and devices) and follow-up care as appropriate to meet the needs of the patient and family.
determined by qualified health care providers in treating any Dental care is medically-necessary to prevent and eliminate
condition, disease, injury, or congenital or developmental orofacial disease, infection, and pain, to restore the form and
malformation to promote optimal health, growth, and devel- function of the dentition, and to correct facial disfiguration or
opment. MNC includes all supportive health care services dysfunction.
that, in the judgment of the attending dentist, are necessary This definition was developed by the Clinical Affairs
for the provision of optimal quality therapeutic and preventive Committee on and adopted in 1997. This document is a
oral care. These services include, but are not limited to, reaffirmation of the previous version, revised in 2015.
sedation, general anesthesia, and utilization of surgical facilities.

DEFINITIONS: SPECIAL HEALTH
DEFINITIONS: DENTALCARE
DISABILITY
NEEDS
Definition of Special Health Care Needs

Latest Reaffirmation How to Cite: American Academy of Pediatric Dentistry. Definition of
2020 special health care needs. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:19.
Special health care needs include any physical, developmental, Health care for individuals with special needs requires special-
mental, sensory, behavioral, cognitive, or emotional impair- ized knowledge, as well as increased awareness and attention,
ment or limiting condition that requires medical management, adaptation, and accommodative measures beyond what are
health care intervention, and/or use of specialized services or considered routine.
programs. The condition may be congenital, developmental, or This definition was developed by the Council on Clinical
acquired through disease, trauma, or environmental cause and Affairs and adopted in 2004. This document is a reaffirmation
may impose limitations in performing daily self-maintenance of the previous version, revised in 2016.
activities or substantial limitations in a major life activity.

ORAL HEALTH POLICIES: MEDICALLY-NECESSARY CARE
Oral health policies

Oral health policies represent
the American Academy of
Pediatric Dentistry’s positions
on various public health issues

Policy on Medically-Necessary Care

Latest Revision How to Cite: American Academy of Pediatric Dentistry. Policy on
2019 medically-necessary care. The Reference Manual of Pediatric Dentistry.
Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:22-7.
Purpose and all stakeholders should recognize that cost-effective care

The American Academy of Pediatric Dentistry (AAPD) is not necessarily the least expensive treatment.2
recognizes that dental care is medically-necessary for the Dental care is medically necessary to prevent and eliminate
purpose of preventing and eliminating orofacial disease, in- orofacial disease, infection, and pain, to restore the form and
fection, and pain, restoring the form and function of the function of the dentition, and to correct facial disfiguration
dentition, and correcting facial disfiguration or dysfunction. or dysfunction. Following the U.S. Surgeon General’s report3
emphasizing that oral health is integral to general health,
Methods the U.S. Department of Health and Human Services recom-
This document was developed by the Council on Clinical mended changing perceptions of the public, policy makers,
Affairs and adopted in 2007. This document is an update and healthcare providers so that oral health becomes an ac-
of the last revision from 2015. It includes an electronic cepted component of general health.4,5 Oral diseases can have
® ®
search with Scopus and PubMed /MEDLINE using the
terms: medically-necessary care, systemic disease AND oral
a direct and devastating impact on overall health, especially
for those with certain systemic health problems or conditions.
disease, dentistry as medically-necessary care, periodontal Caries is the most common chronic disease of childhood. 3
disease AND cardiovascular disease, oral health AND Approximately 60 percent of children experience caries in
pregnancy, oral health AND respiratory illness, oral health their primary teeth by age five. 6 Between 1988-1994 and
AND quality of life, pediatric dentistry, general anesthesia, 1999-2004, prevalence of caries in primary teeth increased
and nutritional deficiency cognitive development; fields: for youths aged two to 11 years, with a significant increase
all; limits: within the last 15 years, human, English. The noted for those in the two to five year age range.7 By 17
reviewers agreed upon the inclusion of 76 articles that met years of age, 78 percent of children in the U.S. have ex-
the defined criteria. perienced caries. 5 As much as 90 percent of all caries in
school-aged children occurs in pits and fissures. Caries,
Background periodontal diseases, and other oral conditions, if left un-
The AAPD defines medically-necessary care (MNC) as “the treated, can lead to pain, infection, and loss of function.
reasonable and essential diagnostic, preventive, and treatment These undesirable outcomes can adversely affect learning,
services (including supplies, appliances, and devices) and communication, nutrition, and other activities necessary for
follow-up care as determined by qualified health care pro- normal growth and development. 8 Rampant caries is asso-
viders in treating any condition, disease, injury, or congenital ciated with insufficient development in children who have
or developmental malformation to promote optimal health, no other medical problems.9 Children with early childhood
growth, and development. MNC includes all supportive caries (ECC) may be severely underweight because of the
health care services that, in the judgment of the attending associated pain and disinclination to eat. Nutritional deficien-
dentist, are necessary for the provision of optimal quality cies during childhood can impact cognitive development.10,11
therapeutic and preventive oral care. These services include, Other oral conditions also can impact general health and
but are not limited to, sedation, general anesthesia, and utili- well-being. Gingivitis is nearly universal in children and
zation of surgical facilities. MNC must take into account adolescents, and children can develop severe forms of
the patient’s age, developmental status, and psychosocial periodontitis.12 A relationship may exist between periodontal
well-being, in addition to the clinical setting appropriate to disease and cardiovascular disease13-15 as well as periodontal
meet the needs of the patient and family.”1 disease and adverse pregnancy outcomes, 16,17 including
MNC is based upon current preventive and therapeutic pregnancy hypertension.18 An association between oral health
practice guidelines formulated by professional organizations and respiratory diseases has been recognized. 18,19 Oral
with recognized clinical expertise. Such recommendations health, oral microflora, and bacterial pneumonia, especially
ideally are evidence based but, in the absence of conclusive
evidence, may rely on expert opinion and clinical observa-
tions. Expected benefits of care should outweigh potential ABBREVIATIONS
risks. MNC increases the probability of good health and AAPD: American Academy Pediatric Dentistry. CC: Chronic condi-
well-being and decreases the likelihood of an unfavorable tion. ECC: Early childhood caries. MNC: Medically-necessary care.
outcome. Value of services is an important consideration,

in populations at high risk for respiratory disease, have been individualized preventive plan based on a caries-risk assess-
linked. The mouth can harbor respiratory pathogens that may ment is the key component of caries prevention. Because
be aspirated, resulting in airway infections.20 Furthermore, any risk assessment tool may fail to identify all infants at risk
dental plaque may serve as a reservoir for respiratory pathogens for developing ECC, early establishment of the dental home
in patients who are undergoing mechanical ventilation.21 is the ideal approach for disease prevention.41 Early diagnosis
Problems of esthetics, form, and function can affect the and timely intervention, including necessary referrals, can
developing psyche of children, with life-long consequences prevent the need for more extensive and expensive care often
in social, educational, and occupational environments.22,23 required when problems have gone unrecognized and/or
Self-image, self-esteem, and self-confidence are unavoidable untreated.42-44
issues in society, and an acceptable orofacial presentation is When very young children have not been the beneficiaries
a necessary component of these psychological concepts.24,25 of adequate preventive care and subsequently develop ECC,
Congenital or acquired orofacial anomalies (e.g., ectoder- therapeutic intervention should be provided by a practitioner
mal dysplasia, cleft defects, cysts, tumors) and malformed with the training, experience, and expertise to manage both
or missing teeth can have significant negative functional, the child and the disease process. Because of the aggressive
esthetic, and psychological effects on individuals and their nature of ECC, restorative treatment should be definitive yet
families.26,27 Patients with craniofacial anomalies often require specific for each individual patient. Conventional restorative
specialized oral health care as a direct result of their cranio- approaches may not arrest the disease.45 Areas of demineral-
facial condition. These services are an integral part of the ization and hypoplasia can cavitate rapidly. The placement of
rehabilitative process.26 Young children benefit from esthetic stainless steel crowns may be necessary to decrease the number
and functional restorative or surgical techniques and readily of tooth surfaces at risk for new or secondary caries. Stainless
adapt to appliances that replace missing teeth and improve steel crowns are less likely than other restorations to require
function, appearance, and self-image. During the period of retreatment. 45,46 Low levels of compliance with follow-up
facial and oral growth, appliances require frequent adjustment care and a high recidivism rate of children requiring additional
and must be remade as the individual grows. treatment also can influence a practitioner’s decisions for
Professional care is necessary to maintain oral health,3,4 and management of ECC47 and may decrease success of a disease
risk assessment is an integral element of contemporary pre- management approach to ECC.48
ventive care for infants, children, adolescents, and persons Sealants are particularly effective in preventing pit and
with special health care needs. 28 The goal of caries-risk fissure caries and providing cost savings if placed on the teeth
assessment is to prevent disease by identifying and mini- of patients during periods of greatest risk. 49 Children with
mizing causative factors (e.g., microbial burden, dietary habits, multiple risk factors and tooth morphology predisposed to
dental morphology) and optimizing protective factors (e.g., plaque retention (i.e., developmental defects, pits and fis-
fluoride exposure, personal oral hygiene, sealants).29,30 Ideally, sures) benefit from having such teeth sealed prophylactically.
risk assessment and implementation of preventive strategies A child who receives sealants is 72 percent less likely to
would occur before the disease process has been initiated. receive restorative services over the next three years than
Infants and young children have unique caries-risk factors children who do not.50 Sealants placement on primary molars
such as ongoing establishment of oral flora and host defense in young children is a cost-effective strategy for children at
systems, susceptibility of newly erupted teeth, and develop- risk for caries, including those insured by state Medicaid
ment of dietary habits and childhood food preferences. programs. 51,52 Although sealant retention rates initially are
Children are most likely to develop caries if Mutans strepto- high, sealant loss does occur.53 It is in the patient’s interest to
cocci is acquired at an early age.31-33 High-risk dietary practices receive periodic evaluation of sealants. With follow-up care,
are multi-factorial.34 Food preferences appear to be established the success rate of sealants may be 80 to 90 percent, even
early (probably by 12 months of age) and are maintained after a decade.53
throughout early childhood. 35-36 Adolescence can be a time Sealants are safe and effective, yet their use continues to
of heightened caries activity and periodontal disease due be low. 53-55 Initial insurance coverage for sealants often is
to an increased intake of cariogenic substances and inattention denied, and insurance coverage for repair and/or replacement
to oral hygiene procedures.37-39 may be limited.55,56 While all Medicaid programs reimburse
An analysis of caries risk includes determination of dentists for placement of sealants on permanent teeth, only
protective factors, such as fluoride exposure. More than one in three reimburses for primary molar sealants. 57 While
one-third of the U.S. population does not benefit from some third-party carriers restrict reimbursement for sealants
community water fluoridation.3 Fluoride contributes to the to patients of certain ages, it is important to consider that
prevention, inhibition, and reversal of caries. 40 Therefore, timing of dental eruption can vary widely. Furthermore, car-
early determination of a child’s systemic and topical fluoride ies risk may increase at any time during a patient’s life due
exposure is important. Children experiencing caries as infants to changes in habits (e.g., dietary, home care), oral micro-
and toddlers have a much greater probability of subsequent flora, or physical condition, and previously unsealed teeth
caries in both the primary and permanent dentitions.10 An subsequently might benefit from sealant application.53,58

The extent of the disease process, as well as the patient’s companies interpret dental appliance construction to be solely
developmental level and comprehension skills, affect the esthetic, without taking into consideration the restorative
practitioner’s behavior guidance approaches. The success of function. For instance, health care policies may provide re-
restorations may be influenced by the child’s response to the imbursement for the prosthesis required for a congenitally
chosen behavior guidance technique. To perform treatment missing extremity and its replacement as the individual grows
safely, effectively, and efficiently, the practitioner caring for but deny benefits for the initial prosthesis and necessary
a pediatric patient may employ advanced behavior guidance periodic replacement for congenitally missing teeth. Third-
techniques such as protective stabilization and/or sedation or party payors frequently will refuse to pay for oral health care
general anesthesia.59,60 The patient’s age, dental needs, disabil- services even when they clearly are associated with the complete
ities, medical conditions, and/or acute situational anxiety rehabilitation of the craniofacial condition.75,76
may preclude the patient’s being treated safely in a traditional
outpatient setting.61,62 For some infants, children, adolescents, Policy statement
and persons with special health care needs, treatment under Dental care is medically necessary to prevent and eliminate
sedation or general anesthesia in a hospital, outpatient facility, orofacial disease, infection, and pain, to restore the form and
or dental office or clinic represents the only appropriate method function of the dentition, and to correct facial disfiguration
to deliver necessary oral health care.59,63 Failure by insurance or dysfunction. MNC is based upon current preventive and
companies to cover general anesthesia costs, hospital fees, and/ therapeutic practice guidelines formulated by professional
or sedation costs can expose the patient to multiple ineffective, organizations with recognized clinical expertise. Expected
potentially unsafe, and/or psychologically traumatic in-office benefits of MNC outweigh potential risks of treatment or no
experiences. The impact of chronic conditions (CC) status and treatment. Early detection and management of oral condi-
CC severity increases the odds of receiving dental treatment tions can improve a child’s oral health, general health and
under general anesthesia.64 Although general anesthesia may well-being, school readiness, and self-esteem. Early recognition,
provide optimal conditions to perform restorative procedures, prevention, and intervention could result in savings of health
it can add significantly to the cost of care.65 General anesthesia care dollars for individuals, community health care programs,
may be required in the hospital setting due to the extent of and third-party payors. Because a child’s risk for developing
treatment, the need to deliver timely care, or the patient’s dental disease can change over time, continual professional
medical history/CC (e.g., cardiac defects, severe bleeding dis- reevaluation and preventive maintenance are essential for good
orders, limited opening due to orofacial anomalies). General oral health. Value of services is an important consideration,
anesthesia, under certain circumstances, may offer a cost-saving and all stakeholders should recognize that cost-effective care
alternative to sedation for children with ECC.66.67 is not necessarily the least expensive treatment.
Reimbursement issues defined by the concept of MNC The AAPD encourages:
have been a complicated topic for dentistry. Pediatric den- 1. Oral health care to be included in the design and pro-
tal patients may be denied access to oral health care when vision of individual and community-based health care
insurance companies refuse to provide reimbursement for programs to achieve comprehensive health care.
sedation/general anesthesia and related facility services. Most 2. Establishment of a dental home for all children by 12
denials cite the procedure as “not medically-necessary”.68 This months of age in order to institute an individualized
determination appears to be based on arbitrary and inconsis- preventive oral health program based upon each pa-
tent criteria.69-74 For instance, medical policies often provide tient’s unique caries risk assessment.
reimbursement for sedation/general anesthesia or facility fees 3. Healthcare providers who diagnose oral disease to either
related to myringotomy for a three-year-old child, but deny provide therapy or refer the patient to a primary care
these benefits when related to treatment of dental disease dentist or dental/medical specialist as dictated by the
and/or dental infection for the same patient. American Den- nature and complexity of the condition. Immediate
tal Association Resolution 1989-546 states that insurance intervention is necessary to prevent further dental de-
companies should not deny benefits that would otherwise struction, as well as more widespread health problems.
be payable “solely on the basis of the professional degree and 4. Evaluation and care provided for an infant, child, or
licensure of the dentist or physician providing treatment, if adolescent by a cleft lip/palate, orofacial, or craniofacial
that treatment is provided by a legally qualified dentist or deformities team as the optimal way to coordinate and
physician operating within the scope of his or her training deliver such complex services.
and licensure.”74 5. The dentist providing oral health care for a patient to
Patients with craniofacial anomalies often are denied third- determine the medical indication and justification for
party coverage for initial appliance construction and, more treatment. The dental care provider must assess the
frequently, replacement of appliances as the child grows. patient’s developmental level and comprehension skills,
The distinction between congenital anomalies involving the as well as the extent of the disease process, to determine
orofacial complex and those involving other parts of the the need for advanced behavior guidance techniques
body is often arbitrary and unfair. Often, medical insurance such as sedation or general anesthesia.

Furthermore, the AAPD encourages third-party payors to: Health Service, National Institute of Health, National
1. Recognize malformed and missing teeth are resultant Institute of Dental and Craniofacial Research; NIH
anomalies of facial development seen in orofacial anom- Publication No. 03-5303, May, 2003. Available at: “https:
alies and may be from congenital defects. Just as the //www.ncbi.nlm.nih.gov/books/NBK47472/”. Accessed
congenital absence of other body parts requires care August 10, 2019.
over the lifetime of the patient, so will these. 6. Dye BA, Tan S, Smith V, et al. Trends in oral health
2. Include oral health care services related to these facial status: United States, 1988-1994 and 1999-2004. Na-
and dental anomalies as benefits of health insurance tional Center for Health Statistics. Vital Health Stat 11
without discrimination between the medical and dental 2007;(248):1-92. Available at: “https://www.cdc.gov/
nature of the congenital defect. These services, optimally nchs/data/series/sr_11/sr11_248.pdf ”. Accessed August
provided by the craniofacial team, include, but are not 10, 2019.
limited to, initial appliance construction, periodic exam- 7. Crall JJ. Development and integration of oral health
inations, and replacement of appliances. services for preschool-age children. Pediatr Dent 2005;
3. End arbitrary and unfair refusal of compensation for 27(4):323-30.
oral health care services related to orofacial and dental 8. American Academy of Pediatric Dentistry. Definition of
anomalies. dental neglect. Pediatr Dent 2016;38(special issue):13.
4. Recognize the oral health benefits of dental sealants 9. Khanh LN, Ivey SL, Sokal-Gutierrez K, et al. Early
and not base coverage for sealants on permanent and childhood caries, mouth pain, and nutritional threats in
primary teeth on a patient’s age. Vietnam. Amer J Pub Health 2015;105(12):2510-7.
5. Ensure that all children have access to the full range of 10. Nyaradi A, Li J, Hickling S, Foster J, Oddy WH. The role
oral health delivery systems. If sedation or general anes- of nutrition in children’s neurocognitive development,
thesia and related facility fees are payable benefits of a from pregnancy through childhood. Front Hum Neurosci
health care plan, these same benefits shall apply for the 2013;7:97. Available at: “http://ncbi.nlm.nih.gov/pmc/
delivery of oral health services. articles/PMC3607807”. Accessed August 10, 2019.
6. Regularly consult the AAPD with respect to the devel- 11. Taylor RM, Fealy SM, Bisquera A, et al. Effects of nutri-
opment of benefit plans that best serve the oral health tional intervention during pregnancy on infant and child
interests of infants, children, adolescents, and persons cognitive outcomes: A systematic review and meta-analysis.
with special health care needs, especially those with Nutrients 2017;9(11):1265-97.
craniofacial or acquired orofacial anomalies. 12. American Academy of Pediatric Dentistry. Classification
of periodontal diseases in infants, children, adolescents,
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52(3):407-15. conscious sedation. Pediatr Dent 2000;22(1):27-32.
53. Feigal RJ. The use of pit and fissure sealants. Pediatr Dent 67. Prabhu NT, Nunn JH, Evans DJ. A comparison of costs
2002;24(5):415-22. in providing dental care for special needs patients under
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1033-40. Extensions. Medically necessary dental services. In; Field
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org/~/media/ADA/Member%20Center/Members/ necessity of dental sedation and general anesthesia? A
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procedures. Pediatr Dent 2019;41(4):E26-E52.

ORAL HEALTH POLICIES: SOCIAL DETERMINANTS OF ORAL HEALTH
Policy on Social Determinants of Children’s Oral

Health and Health Disparities
Adopted How to Cite: American Academy of Pediatric Dentistry. Policy on so-
2017 cial determinants of children’s oral health and health disparities. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy
of Pediatric Dentistry; 2020:28-31.
The American Academy of Pediatric Dentistry (AAPD) over the life course. Various conceptual models from dentistry
recognizes the influence of social factors on children’s oral health include SDH as upstream factors that influence oral health
including access to care, dental disease, behaviors, and oral behaviors, dental disease rates, and oral health outcomes.6-11
health inequalities. The AAPD encourages oral health profes- From a social justice perspective, addressing the SDH is a
sionals and policymakers to formally acknowledge the role longer-term aspirational goal to improve oral health outcomes
that social determinants of health (SDH) have in producing and reduce inequalities for children from socioeconomic vul-
and perpetuating poor oral health and oral health inequalities nerable families and communities. A more immediate strategy
in children. Moreover, AAPD encourages the implementation is to ensure that interventions, programs, and policies properly
of oral health promotion strategies that account for the SDH acknowledge and account for the SDH.
and appropriate clinical management protocols informed In 2013, the American Academy of Pediatrics published
by and sensitive to the SDH. All relevant stakeholders (e.g., a policy statement entitled Community Pediatrics: Navigating
health professionals, researchers, educators) are encouraged to the Intersection of Medicine, Public Health, and Social
develop strategies that incorporate SDH-related knowledge Determinants of Children’s Health.12 This statement included
to improve oral health behaviors, prevent dental disease, and a reference to dental caries, which is an important acknowl-
address oral health inequalities in children. edgement of SDH and children’s oral health. However, the
statement did not include references from the scientific
Methods literature that provide empirical evidence for SDH, which
This policy, developed by the Council on Clinical Affairs, is has grown substantially in dentistry since 2013.
based on a review of the current literature, including a search Findings from the social determinants of children’s oral
®
of PubMed /MEDLINE database using the terms: social
determinants AND dental; fields: all; limits: English. A total
health literature can be organized into categories that provide
guidance on how dentists, other health professionals, re-
of 405 articles matched these criteria. Articles for review were searchers, educators, and policy makers can account for the
selected from this list, the references within selected articles, SDH to improve children’s health outcomes. Examples are
and other articles from the literature. provided of past efforts and future opportunities to address
children’s oral health inequalities through SDH-based inter-
Background ventions, programs, and policies.
The World Health Organization defines social determinants of SDH are commonly measured at the caregiver- or house-
health as “the conditions in which people are born, grow, hold-level. The SDH that affect caregiver oral health outcomes
work, live, and age, and the wider set of forces and systems similarly affect their children. 13 Weak social ties and social
shaping the conditions of daily life”.1 The concept of SDH networks are associated with poor oral health outcomes.14-17
is based on the premise that improving social conditions is a Potential mechanisms include reduced health information that
necessary precursor for improving health outcomes for vul- is transmitted through social ties and networks and increased
nerable populations, ameliorating inequalities, and achieving allostatic load or stress, which is implicated in poor oral health
health equity and social justice. Health equity is defined as behaviors and higher caries rates.18 This is particularly worri-
“the absence of systematic disparities in health between some from a life course perspective.19 A small cross-sectional
and within social groups that have different levels of under- study suggests that chronic stress is related to higher levels
lying social advantages or disadvantages”. 2 Past work has of dental caries in children potentially by affecting intraoral
demonstrated gradients in oral health outcomes based on so- bacteria,20 findings that need to be validated with additional
cioeconomic position.3 Measures of socioeconomic position
include income, educational attainment, occupation, and race/
ABBREVIATIONS
ethnicity.4,5 SDH are influenced by socioeconomic position
AAPD: American Academy Pediatric Dentistry. SDH: Social
and more broadly embody the social environment and con- determinants of health.
text in which individuals live and make health-related decisions

studies. Furthermore, poverty and stress could influence child Directly addressing the SDH will involve systematic policy
behaviors in dental settings, including the ability to cooperate and environmental changes that improve living conditions
for dental procedures, 21,22 which has not yet been tested and alleviate poverty. Examples include universal housing
empirically. There are other oral health examples of social and programs, health insurance programs like Medicare for older
biological interactions.23 Other examples of SDH include Americans and Medicaid and Children’s Health Insurance
household food insecurity (defined as disrupted eating patterns Program (CHIP) for children, and programs that prevent food
with or without reduced food intake)24 and overcrowding.25,26 insecurity. Broader policies are likely to have the long-term
These factors can make it difficult for families to purchase impact needed to improve the conditions in which vulnerable
healthy foods and to have designated spaces in the home for families and children live.
important routines like toothbrushing. Children living in set-
tings with multiple social risks are at substantially greater risk Policy Statement
for caries.27 Many of these relationships need to be elucidated Recognizing the importance of the social determinants of
with additional studies. oral health for children, the AAPD:
SDH are also measured within neighborhoods and com- • supports broader policies and programs that help to
munities. Neighborhood income is positively associated with alleviate poverty and social inequalities.
oral health-related behaviors like improved oral hygiene • encourages dentists and the oral health care team to
practices and lower dental disease levels for children. 15,28-31 In provide anticipatory guidance that is sensitive to the
addition, higher levels of income inequality within a commu- SDH, which involves collecting a social history from
nity are associated with poorer oral health outcomes.32 Another patients.42
important SDH is social capital, which is defined as resources • supports inter-professional educational approaches to
that result from networks33 and other sources like community train students as well as practicing dentists and health
centers.34 Over 60 percent of women of childbearing age reside professionals on the social determinants of health.43-46
in neighborhoods with very poor or poor levels of social • endorses interdisciplinary theory-based intervention
capital.35 Studies generally have reported positive outcomes approaches that account for the social determinants of
associated with greater levels of social capital,36,37 but at least oral health.47,48
one study found negative outcomes.38 These findings suggest • supports additional research to understand mechanisms
that enhancing social capital is beneficial, but that social norms underlying the social determinants of oral health.49
can influence the way in which resources are deployed, which
can lead to suboptimal oral health behaviors and poor outcomes. References
An example of a public health intervention that circum- 1. World Health Organization (WHO). 2016. Social De-
vents the SDH is the Childsmile program in Scotland. 39 terminants of Health. Available at: “http://www.who.
The Childsmile program distributes free toothbrushes and int/social_determinants/sdh_definition/en/”. Accessed
toothpaste to children in communities during early childhood
and to first and second graders living in disadvantaged areas.
October 1, 2016. (Archived by WebCite at: “http://
www.webcitation.org/6siehxcIB”)
®
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referred to dental care support workers who provide dietary Epidemiol Community Health 2003;57(4):254-8.
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program does not attempt to modify SDH but circumvents 992-6.
the SDH by delivering more intense intervention activities 4. Chalub LL, Borges CM, Ferreira RC, et al. Association
within the neediest areas. The Bolsa Família Program is a between social determinants of health and functional
conditional cash transfer program in Brazil, part of a larger dentition in 35-year-old to 44-year-old Brazilian adults:
initiative aimed at improving use of primary care services for A population-based analytical study. Community Dent
disadvantaged children. 40 It does not have a formal oral Oral Epidemiol 2014;42(6):503-16.
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Bolsa Família Program supervisors. The study recommenda- in the frequency of free sugars intake among Syrian
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there is less income inequality41 as well as the political will to 7. Fisher-Owens SA, Gansky SA, Platt LJ, et al. Influences
address oral health inequalities. on children’s oral health: A conceptual model. Pediatrics
2007;120(3):e510-20.

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health. Adv Dent Res 2011;23(2):201-6. biological interactions in oral disease: A ‘cells to society’
9. Chi DL. Reducing Alaska Native paediatric oral health view. PLoS One 2016;11(1):e0146218.
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10. Casamassimo PS, Lee JY, Marazita ML, et al. Improving
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dental caries in the context of mother-child pairs. J Appl children’s dental health and care-utilization within regions
Oral Sci 2014;22(1):73-8. of the United States. Matern Child Health J 2016;20(3):
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Modelling community, family, and individual determi- adolescents in New Delhi, India. BMJ Open 2014;4(12):
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Epidemiol 2015;43(2):172-82. 31. Priesnitz MC, Celeste RK, Pereira MJ, et al. Neighbour-
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2016;44:50-6. 455-61.
18. Masterson EE, Sabbah W. Maternal allostatic load, care- 32. Pattussi MP, Marcenes W, Croucher R, Sheiham A.
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ORAL HEALTH POLICIES: CARE FOR VULNERABLE POPULATIONS
Policy on Care for Vulnerable Populations

in a Dental Setting
Adopted How to Cite: American Academy of Pediatric Dentistry. Policy on care
2020 for vulnerable populations in a dental setting. The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Purpose While the negative oral health consequences for some vul-
The American Academy of Pediatric Dentistry (AAPD) is nerable populations have been established, there are additional
committed to the improvement of healthcare for all children groups that typically have been emphasized less in studies of
and adolescents, regardless of their race, ethnicity, religion, oral health. This document allows for a broader concept of
sexual or gender identity, medical status, family structure, or vulnerability and lends additional information to providers
financial circumstances. Additionally, the AAPD is committed regarding support for such communities. These groups extend
to increased access to dental services and improved oral health beyond the better understood vulnerabilities of poverty and
for all children and adolescents, including those from vulner- special health care needs and include LGBTQ youth, military-
able and underserved communities. The intent of this docu- connected families, families without consistent housing, youth
ment is to increase awareness of the challenges that vulnerable with mental illness, and immigrants. While by no means
populations face in achieving optimal oral health, to educate comprehensive in its list of vulnerable groups, this document
providers regarding the importance of culturally-sensitive care, discusses barriers to care that may be applicable to additional
and to encourage oral health professionals to advocate for populations.
improved access to dental services for vulnerable communities. Many pediatric dentists take active roles in their communi-
ties as advocates for children’s health beyond the responsibilities
Methods of providing healthcare. It is important that dentists maintain
This policy was developed by the Council on Clinical Affairs. an awareness of the various social determinants of oral health4
This document is based on a review of current dental and and approach care for their patients with cultural sensitivity.
®
medical literature, including search of the PubMed and Google Dentists should be aware of the particular vulnerabilities of
their patients when it comes to their health and are encouraged
Scholar databases combining the word dental with the follow-
ing terms: vulnerable populations; special health care needs to advocate for and seek out resources that would benefit their
(SHCN); lesbian; gay; bisexual; transgender; lesbian, gay, patients as individuals and as a community.
bisexual, transgender, questioning (LGBTQ); homosexuality;
sexual minority; gender diverse; homeless children; foster Youth in the juvenile justice system
children; military-connected AND children; immigrant; Adolescents who have passed through the juvenile justice
incarcerated youth; mental health; fields: all; limits: within system constitute a vulnerable population due to higher rates
the last 10 years, human, English. Data from 67 articles met of health risky behaviors, limited access to healthcare, and
these criteria. Papers for review were chosen from this list sociodemographic factors. Over 850,000 arrests of youth
and from references within selected articles. Expert opinions younger than 18 were made in 2016.5 The number of youth
and the best current practices were relied upon when clinical in residential placement varies, but recent census data reports
evidence was not available. more than 40,000 juveniles may be assigned to residential
placement on any given day.6 Lack of housing stability, dis-
Background ruptions in education, and other sequelae of poverty correlate
Vulnerable populations are communities that have limited with higher rates of arrests among youth from low socio-
access to healthcare for many reasons including geography, economic backgrounds.7 Incarcerated youth have higher rates
finances, medical status, age, and societal discrimination. Such
vulnerability may be temporary or permanent, and status may
be improved or exacerbated by social and economic policies at ABBREVIATIONS
the state and federal level. Negative health sequelae of limited AAPD: American Academy Pediatric Dentistry. ADHD: Attention
access to care among vulnerable populations include dispro- deficit hyperactivity disorder. LGBT: Lesbian, gay, bisexual, or trans-
gender. LGBTQ: Lesbian, gay, bisexual, transgender, questioning.
portionately poor oral and systemic health status and lower SHCN: Special health care needs. TGD: Transgender or gender
utilization rates of preventive services.1-3 diverse.

of health risky behaviors, particularly in the realm of mental children are attention deficit hyperactivity disorder (ADHD),
and sexual health.8,9 Nationwide, it was found that two-thirds behavior problems, anxiety, and depression. 15 According to
of juvenile detention facilities hold youth without criminal recent data, over six million children under the age of 18 have
charges who are awaiting community mental health services.10 been diagnosed with ADHD, 4.4 million with anxiety, and
The oral health of youth in juvenile detention centers may 1.9 million with depression.15 Unfortunately, only about 20
be compromised by a lack of comprehensive treatment and percent of those children diagnosed with a mental health con-
continuity of care and concomitant health risky behaviors. dition receive treatment for their disorder.16 Worldwide, people
There is a dearth of current studies on the oral health of in- with mental health disorders may be subject to social stigma-
carcerated youth. One study of a detention center in Texas tization and discrimination, higher rates of physical and sexual
found significantly higher rates of untreated decay and low violence, and limitations to their participation in civic life and
rates of preventive measures among its residents compared to public affairs. Their ability to access essential health care and
non-incarcerated youth.11 Urgent dental problems including social services, including emergency services, may be challenging.17
infection, tooth and jaw fractures and severe periodontal di- People with behavioral or mental health conditions are
sease were found in over six percent of the subjects included susceptible to worsened oral health. Those with depressive
in the study.11 Juvenile detention and confinement facilities are disorders may experience fatigue and lack of motivation for
required to provide a dental examination by a licensed dentist self-care that impedes proper home oral hygiene. Anxiety or
within 60 days of admission.12 Beyond the examination, how- depression can lead to lower self-esteem and dental fears that
ever, youth in detention facilities may have dental needs that make one less likely to seek professional dental care.18 Such
are addressed only on an emergency basis, without access to risk factors may cause increased rates of dental decay and tooth
routine care and without family, school, or community loss, which in turn exacerbate mental health conditions by
resources to facilitate management of their dental needs. contributing to social withdrawal, low self-esteem, and diffi-
Dental providers offering care within detention facilities culty with functions such as eating and speaking.19 Children
may have explicit biases toward youth in custody, and they and adolescents with ADHD may be prone to dental injuries
may doubt the truthfulness of symptoms reported by these pa- and bruxism habits.20-22 Xerostomia is a known side effect of
tients. Biases and doubts may cause a delay in diagnoses or multiple psychotropic medications.19 Those patients at risk for
treatment.13 Additional challenges in caring for youth in de- xerostomia should be educated on proper fluoride use and in-
tention facilities include scheduling appointments, security creased frequency of water intake. Eating disorders may start
concerns, transportation considerations, lack of legal guardian in childhood and more commonly in adolescence and have
presence, and availability of providers.14 Once released from the highest rate of mortality of any mental health condition.23
detention facilities, juveniles may face hardships establishing Eating disorders can result in detrimental oral health behaviors
care and preventive services due to lack of family involvement with consequences including severe erosion of enamel and
and external support, difficulties adjusting to their previous increased risk of dental caries.24 Dentists should be aware of
environment, problems accessing previous medical records, intraoral signs of eating disorders and be prepared to discuss
and challenges in obtaining insurance coverage.7 concerns with their patients and families.
Dental providers should be aware of these challenges when Dentists should consider the mental health of their patients
treating incarcerated youth. Ideally, efforts to establish a and inquire about their psychiatric management, including
dental home and to reinstate insurance coverage should be behavior modification strategies 25, medications, and home
made prior to release from the facility. Providers are encour- hygiene practices. They are encouraged to connect with men-
aged to connect with social services in their communities to tal health provider networks and refer patients for counseling
facilitate ongoing care for previously incarcerated youth. for concerns that have not yet been addressed by a mental
Incarcerated youth should be provided with the same standard health professional.
of care as non-incarcerated individuals and should receive
comprehensive dental examinations within a defined amount Individuals with special health care needs
of time in detention. Efforts should be made by dental Individuals with SHCN are among the many vulnerable
providers to connect patients to other healthcare services populations who suffer profound health disparities.26-31 Those
within the facility, particularly when oral manifestations of who treat individuals with SHCN need specialized knowledge,
systemic diseases are recognized in youth who have not yet training, awareness, and willingness to accommodate
been evaluated by a physician.8 patients beyond routine measures.32 Although children with
SHCN utilize preventive dental care at equal or higher rates
Youth with mental health conditions or behavioral when compared to children without SHCN, dental care
disorders continues to be the most common unmet healthcare need
One out of every five children in the United States has been among this population. 26-29 In fact, low-income children
diagnosed with a mental health disorder. 14 Mental health with the most severe healthcare conditions are more likely
conditions vary in terms of cause, incidence, and severity. The to have unmet dental needs. 26,27 Individuals with SHCN
most commonly diagnosed mental health conditions in face many barriers to obtaining adequate oral health care

including competing medical priorities, difficulties finding a Immigrant youth and families
knowledgeable and willing provider, residing in rural locations, Immigrant children and families present unique needs and
transportation issues, inadequate insurance, and caregivers can encounter barriers to oral health as a vulnerable population.
factors such as depression, low levels of functioning, and fi- In 2017, 18.2 million children in the United States lived with
nancial burdens of caring for an individual with SHCN.26-30 one immigrant parent.43 Children who grow up in a multicul-
An integral part of the specialty of pediatric dentistry is to tural setting can experience differences in their oral health if
provide comprehensive preventive and therapeutic oral health there is a difference between parental or cultural views and the
care to individuals with SHCN.33 Failure to accommodate mainstream culture.44 Children who have recently immigrated
patients with SHCN could be considered discrimination and a are at an increased risk for caries.44,45 Language barriers, insur-
violation of federal and/or state law.34 Therefore, when the ance coverage, available providers, as well as cultural views can
needs of an individual with SHCN are beyond the skills of create barriers in accessing oral healthcare.44 Acceptance of
the dentist, the patient should be referred to a practitioner health interventions as well as responses to health information
who is comfortable, knowledgeable, and appropriately trained can be affected by an individual or family’s culture.43 It is im-
to manage the patient’s individual oral health care needs. portant that providers understand and consider these factors
when treating immigrant children and families.
LGBTQ youth Oral health messages can be developed with special con-
LGBTQ is an initialism that is used to describe those sideration to a community’s cultural beliefs, motivation, and
individuals who identify as lesbian, gay, bisexual, transgender, knowledge. Acceptance of oral health care recommendations
or questioning.35 TGD also may be used to describe individ- and treatment may be improved by training community
uals that identify as transgender or gender diverse.35 LGBTQ members to participate in the delivery of care to families.44
and TGD individuals and their families may face disparities Involvement of a greater network or community members in
stemming from inequitable laws and policies, encounter so- the delivery of care can foster trust in the dental provider. De-
cietal discrimination, and lack access to quality health care.35 livering oral health information that considers a gain-framed
Individuals identified as lesbian, gay, bisexual, or transgender or loss-framed approach based on cultural background and
(LGBT) present to dental providers with unique oral health acculturation can improve responsiveness.43 Immigrant families
needs36 and are at greater risk for poor health conditions.37 It with greater exposure to the mainstream culture may respond
is, therefore, imperative that dental offices be willing and more positively to gain-framed messaging. An example of a
prepared to treat individuals of all backgrounds, including gain-framed message would be if one brushes twice daily, the
those who identify as LGBTQ or TGD. individual will have better oral health. 46 Immigrant families
Many LGBTQ or TGD individuals face stigma and dis- with less exposure to the mainstream culture may respond
crimination35 and experience stress and anxiety in healthcare better to loss-framed messaging.46 An example of a loss-framed
settings.37 Dental fear among transgender individuals has been message would be if one does not brush twice daily, the
associated with prior experiences and fears of discrimination.38 individual risks having poor gingival health and caries. Den-
For these reason, some patients may not feel comfortable distal providers should make efforts to understand the cultural
closing their sexual orientation, gender identity, or expression.39,40 backgrounds of immigrant patients and families and utilize
Providers are encouraged to create a welcoming office environ- many approaches to improve their delivery of care.
ment for patients who identify as LGBTQ or TGD. Examples
include using gender neutral terms39,40 and placing a rainbow Military-connected youth
decal or button that is easily seen by patients. Intake forms Military-connected youth face challenges and vulnerabilities
can be modified to include questions about the patient’s caused by the unique requirements of military life. Providing
preferred pronoun, sex at birth, preferred gender, and legal and care to military-connected youth requires appropriate knowl-
preferred names 39 and should ask for parent rather than edge, understanding, and appreciation of military culture.47
mother/father information. These efforts demonstrate The Armed Services represent a culturally and ethnically diverse
inclusion of parents and legal guardians who are in same-sex population with 31 percent of the force represented by racial
relationships and indicate that the office is open and minorities,48 and 16.4 percent of service members are females.48
welcoming to individuals of diverse sexual orientation, gender In 2018, over 1.5 million dependent children were reported to
identity, or expression.40 be living in active duty, guard, and reserve families. 48 Along
Professional education regarding oral health and oral health with the approximately two million children of veterans, the
disparities of individuals identified as LGBTQ is lacking. In a total number of military-connected children in the United States is
2016 survey of United States and Canadian dental schools, 29 nearly four million.48
percent of responding schools did not offer any LGBT content, Military-connected children may grow up without the
and 12 percent did not know if content was covered.39 Proper physical presence of a parent due to frequent deployments,
trainingof health care providers to take care of these missions, training exercises, and school.47 Deployment and its
individuals 35,41 and more evidence-based research regarding dangers can threaten a child’s sense of security and can result
LGBT health and health disparities are needed.42 in complex psychosocial burdens. 47-51 Military-connected

families experience frequent relocations involving the changing Foster caretakers often are challenged with the inability to
of schools and social networks. Some evidence suggests that consent for needed dental care and rely on social services to
military-connected children cope well with relocation and assist with obtaining consent from legal authorities.60-62 A
experience lower risk behaviors when compared to civilian recent study found that youth in foster care were more likely
counterparts.50 Conversely, other resources point to more risk to experience caries in both the primary and permanent den-
behaviors and depressed mood as a result of parental military tition than other children who were enrolled in Medicaid.60
service.52 Some military-connected children may experience Every year, more than 2.5 million children will experience
marginalization and victimization52 while others face problems a period of homelessness in the United States.63 Approximately
in communities where there is a lack of sensitivity to or prepa- 40 percent of homeless in the United States are under the age
ration for dealing with military-connected difficulties.51 Child of 18.64 The main cause of youth homelessness is physical,
maltreatment and neglect are concerns for military-connected sexual, and/or emotional abuse from parents or guardians.63 As
children.53 Some studies demonstrated an elevated risk while many as 20,000 homeless youth are forced into prostitution by
others show risk comparable to civilian populations.53-56 human trafficking.65 Approximately half of youths who age out
Reestablishing medical and dental homes is a common of foster care or the juvenile justice system will be homeless
challenge military-connected families face. Although military within six months.63 Youth who are homeless face challenges
families have health insurance coverage, a recent study found in obtaining dental care including transportation, consent for
military-connected children are more likely to have special treatment, and general dental knowledge.66 A homeless minor
health care needs and behavioral health needs when compared may be able to provide consent for treatment based on indi-
with civilian peers.57 Furthermore, frequent relocations may vidual state laws. The 2018 Federal Runaway and Homeless
interfere with continuity of care and leave some medical or Youth Act allows for some youth to have legal rights for treat-
dental problems unresolved. A study on dental care in military ment decisions.67 Homeless youth have a higher caries rate
children found socioeconomic status of the service member than those who have Medicaid.63 Provision of dental services
influenced care seeking behavior.58 Frequent changes in military for youth in foster care or who are homeless should be made
insurance plans may deter some dental offices from accepting available whenever possible. This usually requires additional
or continuing care after changes in coverage. measures on behalf of the dental health professional in order to
Military-connected children may have an increased risk for provide appropriate dental procedures in a safe and empathetic
caries due to deficiencies in protective and biological factors. environment.
A consistent dental home with regular dental care may be
lacking, and fluoride exposure may be suboptimal. Sporadic Policy statement
dental care may be more common because of frequent reloca- Recognizing of the challenges faced by vulnerable populations
tions. Inconsistent fluoride exposure may be expected if in achieving optimal oral health status, the AAPD supports:
children have a history of residing in international or non- • advocacy for programs and policies that support vul-
fluoridated communities. Children in single parent or dual nerable populations in obtaining improved access to
military families also may be at an increased risk for caries. healthcare services.
During work, training, or deployments, military-connected • pre- and post-doctoral programs as well as continuing
children may be enrolled in extensive childcare and after education courses that include training dentists in cul-
school programs or be cared for by extended family where they tural sensitivity and social concerns for vulnerable
have more frequent exposure to cariogenic foods. Dentists populations.
caring for military families are encouraged to be thorough in • inter-professional networks that will aid vulnerable
their discussion of dietary choices and to help connect families populations in accessing important healthcare resources.
to other dentists upon relocation.
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ORAL HEALTH POLICIES: ORAL HEALTH CARE PROGRAMS
Policy on Oral Health Care Programs for Infants,

Children, Adolescents, and Individuals with Special
Health Care Needs
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Policy on oral
2020 health care programs for Infants, children, adolescents, and individuals
with special health care needs. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:
39-42.
Purpose families was 18 percent while that of children from low-income

The American Academy of Pediatric Dentistry (AAPD) families was 42 percent.17,18 Disparities in caries prevalence
recognizes the importance of education, prevention, diagnosis, exist within specific population subgroups in the U.S.19-22 From
and treatment necessary to maintain the oral health of in- 2011-2014, 12.4 million children below the age of 19 in the
fants, children, adolescents, and individuals with special health United States had untreated caries.23 Socioeconomic and demo-
care needs through preventive and restorative care. Compre- graphic differences are cited as barriers for treatment.23
hensive health care cannot be achieved unless oral care is Researchers used the 2016-2017 National Survey of Chil-
included in all health service programs. dren’s Health to analyze a link between oral health status and
academic performance.24 Assessing data from more than 45,000
Methods six-17 year olds, they found poor oral health was strongly
This policy was developed by the Dental Care Programs linked to poor academic performance and missed school
Committee and adopted in 1972.1 This document is an update days.24 This association was consistent across subpopulations
of the previous version, revised in 2016.2 This revision is based defined by age, gender, household income, and type of health
upon a review of current publications and websites of govern- insurance coverage.24
mental agencies and health care organizations. A PubMed / ® New strategies are needed to meet the needs of children
and families and effectively address early childhood caries
MEDLINE search was performed using the terms: oral health
policy, infant oral health policy, child oral health policy, (ECC).18 Primary care medical providers have frequent con-
adolescent oral health policy; oral health for special needs; tact with families, providing opportunities to incorporate oral
fields: all; limits: within the last 10 years, humans, English, health promotion and prevention in non-dental settings. They
birth through age 18. Six hundred thirty-six articles matched can accomplish an oral screening, risk assessment, oral health
these criteria. Papers for review were chosen from this list and counseling, and application of fluoride varnish.18
from references within selected articles. Key findings from the National Health and Nutrition
Examination Survey (NHANES) include:
Background • “For 2015–2016, prevalence of total caries (untreated
The U.S. Department of Health and Human Services (HSS) and treated) was 45.8 percent and untreated caries was
reports that caries is the most prevalent chronic childhood 13.0 percent among youth aged two-19 years.
disease in our nation’s children.3 Early childhood caries affects • Prevalence was lowest in youth aged two–five years
children’s quality of life and their ability to learn and concen- compared with those aged six-11 and 12–19 for total
trate in school.4-6 Although the AAPD7, American Academy of (21.4 percent, 50.5 percent, 53.8 percent) and un-
Pediatrics8, and the American Dental Association9 recommend treated caries (8.8 percent, 15.3 percent, 13.4 percent).
establishment of a dental home by 12 months of age, referral • Hispanic youth had the highest prevalence of total
patterns by primary care providers are inconsistent with this caries; non-Hispanic black youth had the highest
recommendation.10-13 Only nine percent of Medicaid-enrolled prevalence of untreated caries.
children aged one-two years received preventive dental services
in 2008.14 More than 40 percent of children have caries by
the time they reach kindergarten.15 In contrast to declining
ABBREVIATIONS
prevalence of dental caries among children in older age groups, AAPD: American Academy Pediatric Dentistry. AI: Alaskan Indian.
the prevalence of caries in poor U.S. children under the age AN: Alaska native. HSS: U.S. Department of Health and Human
of five is increasing.16 Studies demonstrated caries prevalence Services. IOM: Institute of Medicine.
within the two to five year old age group from higher income

• For both total and untreated caries, prevalence decreased strategies to engage all groups to eliminate health dis-
as family income level increased. parities through health promotion and health literacy,
• Untreated caries prevalence increased from 2011–2012 improve access.
(16.1 percent) to 2013–2014 (18.0 percent) and then • Action 3–Build the Science Base and Accelerate Science
decreased in 2015–2016 (13.0 percent).”25 Transfer-Application of research findings to improve oral
health.
Untreated caries among children two–eight years of age • Action 4–Increase Oral Health Workforce Diversity,
was shown to be twice as high for Hispanic and non-Hispanic Capacity, and Flexibility-Ensure the adequacy of public
African American children in comparison to non-Hispanic and private health personnel and resources to meet the
white children.19 American Indian (AI) and Alaska Native oral health needs of all Americans and enable the inte-
(AN) children demonstrated a higher rate of caries than other gration of oral health effectively with general health.
population groups in the U.S., with approximately 40 percent • Action 5–Increase Collaborations-Develop partnerships
of AI/AN children aged one–five years exhibiting untreated and utilize resources from social services, education, health
caries in contrast to only 11 percent of non-Hispanic white care services at state and local levels, including commu-
children.21 nity groups, voluntary organizations and individuals.”27
HHS reports a perception that oral health is separate from
general health and, therefore, less important.3 By raising oral The Call to Action urges that oral health promotion, dis-
health awareness, the prevention, early detection, and man- ease prevention, and oral health care issues have a presence in
agement of dental, oral, and craniofacial tissues can become all health policy agendas and are discussed at local, state, and
integrated into general health care, community-based pro- national levels.27 Its success relies on shared knowledge and
grams, and social services.3 HHS recognizes that oral health its execution at all levels.27
can have a significant impact on overall health and well-being. As follow-up to Oral Health in America3, the HHS Oral
Major themes of the Oral Health in America: A Report of the Health Initiative 2010 was developed.28 The key statement
Surgeon General 3 include: from this initiative was, “Oral health is integral to overall
• “Oral health means much more than healthy teeth.” health”.28 Total health and wellness cannot exist without oral
• “Oral health is integral to general health.” health. Oral disease can have an impact on physical, psycho-
logical, social, and economic health and well-being through
Oral health integration into the broader health care system pain, diminished function, and reduced quality of life.29
is still viewed as a supplemental benefit, not a priority benefit.26 Through this initiative, programs were created, produced, and
This separate view of oral health negatively impacts our na- financed to:
tion including the increasing use of emergency departments • emphasize oral health promotion and disease prevention.
at substantial cost to treat dental pain and related conditions.26 • increase access to care.
Accordingly, the HHS report National Call to Action to • enhance oral health workforce.
Promote Oral Health 27 included a partnership of public and • eliminate oral health disparities.28
private organizations that specified a vision, goals, and a series
of actions to promote oral health, prevent disease, and reduce The HHS created the Oral Health Strategic Framework,
oral health disparities in vulnerable populations including the 2014-2017 (known as the Framework) which reflects delib-
disadvantaged poor, racial and ethnic groups, individuals living erations and next steps proposed by HHS and other federal
in geographically isolated areas, and those with special oral partners to support the department’s oral health vision and
health care needs. These actions are necessary and define cer- eliminate oral health disparities.30 The Framework has five
tain tasks to assure that all Americans of all ages and those goals:
individuals who require specialized health care services, inter- “1. Integrate oral health and primary health care.
ventions, and programs achieve optimal oral health. 2. Prevent disease and promote oral health.
The five principal actions and implementation strategies 3. Increase access to oral health care and eliminate
that constitute the Call to Action include: disparities.
• “Action 1–Change Perceptions of Oral Health- 4. Increase the dissemination of oral health information
Policymakers, community leaders, private industry, and improve health literacy.
health professionals, the media, and the public are called 5. Advance oral health in public policy and research.”30
upon to raise the level of awareness and understanding
of oral health, affirming that oral health is essential to Federal agencies currently collaborate and through commu-
general health and well-being. nication processes ensure that comprehensive, updated,
• Action 2–Overcome Barriers by Replicating Effective evidence-based health information is disseminated.30 Govern-
Programs and Proven Efforts-Remove known barriers ment agencies and providers continue to engage, develop and
between people and oral health services by implementing implement solutions to improve overall health and well-being.30

The Institute of Medicine (IOM) in 2009 evaluated the of early childhood caries on the oral health-related quality
oral health system for the entire U.S. population and provided of life of preschool children and their parents. Caries Res
recommendations and strategic approaches to the HHS for a 2013;47(3):211-8.
potential oral health initiative.31 Reviewing important factors 7. American Academy of Pediatric Dentistry. Policy on den-
such as care settings, workforce, financing, quality assessments, tal home. The Reference Manual of Pediatric Dentistry.
access to care, and education, the IOM committee focused on Chicago, Ill.: American Academy of Pediatric Dentistry;
these areas and how these factors linked to current and future 2020;43-4.
HHS programs and policies.12 The committee report, Advancing 8. American Academy of Pediatrics Section on Oral Health.
Oral Health in America32, provided recommendations/ Maintaining and improving the oral health of young
organizing principles for a new oral health initiative: children. Pediatrics 2014;134(6):1224-9. Reaffirmed
• establish HHS high-level accountability in evaluating January, 2019.
the oral health initiative. 9. American Academy of Pediatric Dentistry Foundation,
• focusing on disease prevention and oral health promotion. Dental Trade Alliance Foundation, American Dental
• improving oral health literacy and cultural competence. Association. The Dental Home: It’s Never Too Early to
• reducing oral health disparities. Start February, 2007. Available at: “https://www.aapd.
• enhancing the delivery of oral health care. org/assets/1/7/DentalHomeNeverTooEarly.pdf ”. Accessed
• enhance the role of non-dental health care professionals. August 16, 2020.
• expand oral health research and improve data collection. 10. Brickhouse TH, Unkel JH, Kancitis I, Best AM, Davis
• promote collaboration among private and public stake- RD. Infant oral health care: A survey of general dentists,
holders. pediatric dentists, and pediatricians in Virginia. Pediatr
• measure progress toward short-term and long-term goals Dent 2008;30(2):147-53.
and objectives. 11. Chay PL, Nair R, Tong HJ. Pediatricians’ self-efficacy
• advance the goals and objectives of Healthy People 202013. affects frequency of giving oral health advice, conducting
oral examination, and prescribing referrals. J Dent Child
Policy statement 2019;86(3):131-8.
The AAPD advocates that oral health care must be included 12. Zhu Y, Close K, Zeldin L, Quiñonez RB, White BA,
in the design and provision of individual, community-based, Rozier RG. A clinical vignette-based study of physicians’
and national health care programs to achieve comprehensive adherence to guidelines for dental referrals of young
health care. This can be achieved through the recommenda- children. Acad Pediatr 2019;19(2):195-202.
tions of the HHS reports Oral Health Initiative 2010 28 and U.S. 13. Zhu Y, Close K, Zeldin LP, White BA, Rozier RG. Imple-
Department of Health and Human Services Oral Health Strategic mentation of oral health screening and referral guidelines
Framework, 2014-2017 30. in primary health care. JDR Clin Trans Res 2019;4(2):
167-77.
References 14. Bouchery E. Utilization of dental services among
1. American Academy of Pedodontics. Oral health care Medicaid-enrolled children. Medicare Medicaid Res Rev
programs for children and adolescents. Chicago, Ill.: 2013;3(3):E1-E14. Available at: “https://www.cms.gov/
American Academy of Pedodontics; 1972. mmrr/Downloads/MMRR2013_003_03_b04.pdf ”.
2. American Academy of Pediatric Dentistry. Oral health Accessed September 9, 2020.
care programs for infants, children, and adolescents. 15. Pierce KM, Rozier RG, Vann WF Jr. Accuracy of pediatric
Pediatr Dent 2016;38(special issue):23-4. care providers’ screening and referral for early childhood
3. U.S. Department of Health and Human Services. Oral caries. Pediatrics 2002;109(5):E82-2.
Health in America: A Report of the Surgeon General. 16. Dye BA, Tan S, Smith V, et al. Trends in oral health
Rockville, Md.: U.S. Department of Health and Human status: United States, 1988-1994 and 1999-2004. National
Services, National Institute of Dental and Craniofacial Center for Health Statistics, Centers for Disease Control
Research, National Institutes of Health; 2000. and Prevention, U.S. Department of Health and Human
4. Abanto J, Carvalho TS, Mendes FM, Wanderley MT, Services. Vital Health Stat 2007;11(248):1-92.
Bonecker M, Raggio DP. Impact of oral diseases and 17. Dye BA, Arevalo O, Vargas CM. Trends in paediatric
disorders on oral health-related quality of life of preschool dental caries by poverty status in the United States, 1988-
children. Community Dent Oral Epidemiol 2011;39(2): 1994 and 1999-2004. Int J Paediatr Dent 2010;20(2):
105-14. 132-43.
5. Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY. Impact 18. Douglass JM, Clark MB. Integrating oral health into
of poor oral health on children’s school attendance and overall health care to prevent early childhood caries:
performance. Am J Public Health 2011;101(10):1900-6. Need, evidence, and solutions. Pediatr Dent 2015;37(3):
6. Martins-Júnior PA, Vieira-Ansdrade RG, Corrêa-Faria P, 266-74.
Oliveira-Ferreira F, Marques LS, Ramos-Jorge ML. Impact References continued on the next page.

19. Dye BA, Hsu KL, Afful J. Prevalence and measurement 27. Office of the Surgeon General (US). National Call To
of dental caries in young children. Pediatr Dent 2015;37 Action To Promote Oral Health. Rockville, Md.: Na-
(3):200-16. tional Institute of Dental and Craniofacial Research (US);
20. Garcia R, Borrelli B, Vineet D, et al. Progress in early 2003. Available at: “https://www.ncbi.nlm.nih.gov/books/
childhood caries and opportunities in research, policy, and NBK47472/”. Accessed September 9, 2020.
clinical management. Pediatr Dent 2015;37(3):294-9. 28. U.S. Department of Health and Human Services. Oral
21. Phipps KR, Ricks TL. The oral health of American Health Initiative 2010. Rocksville, Md.: U.S. Department
Indian and Alaska Native children aged 1-5 years: Results of Health and Human Services, Health Resources and
of the 2014 IHS oral health survey. Indian Health Ser- Services Administration; 2010. Available at: “https://
vice Data Brief. Rocksville, Md.: Indian Health Service; www.hrsa.gov/sites/default/files/oralhealth/hhsinitiative.
2015. Available at: “http://www.ihs.gov/doh/ documents/ pdf ”. Accessed August 16, 2019.
IHS_Data_Brief_1-5_Year-Old.pdf ”. Accessed August 29. Murthy VH. Surgeon General’s Perspectives. Oral Health
16, 2020. in America, 2000 to Present: Progress made, but chal-
22. Ricks TL, Phipps KR, Bruerd B. The Indian Health lenges remain. Public Health Rep 2016;131(2):224-5.
Service early childhood caries collaborative: A 5-year Available at: “https://journals.sagepub.com/doi/pdf/10.1
summary. Pediatr Dent 2015;37(3):275-80. 177/003335491613100202”. Accessed August 16, 2020.
23. Gupta N, Vujici M, Yarbrough C, Harrison B. Disparities 30. U.S. Department of Health and Human Services Oral
in untreated caries among children and adults in the Health Coordinating Committee. U.S. Department of
U.S., 2011-2014. BMC Oral Health 2018;18:30. Avail- Health and Human Services Oral Health Strategic Frame-
able at: “https://bmcoralhealth.biomedcentral.com/track work, 2014-2017. Public Health Rep 2016;131(2):242-
/pdf/10.1186/s12903-018-0493-7”. Accessed September 57. Available at: “https://www.ncbi.nlm.nih.gov/pmc/
9, 2020. articles/PMC4765973/”. Accessed November 13, 2020.
24. Guarnizo-Herreño CC, Lyu W, Wehby GL. Children’s 31. Institute of Medicine. 2009. Informing the Future: Criti-
oral health and academic performance: Evidence of a cal Issues in Health, Fifth Edition. Washington, D.C.:
persisting relationship over the last decade in the United The National Academies Press. “https://doi.org/10.
States. J Pediatr 2019;209:183-9.e2. Available at: “https:// 17226/12709”. Accessed November 11, 2020.
www.jpeds.com/article/S0022-3476(19)30135-0/fulltext”. 32. Institute of Medicine. Advancing Oral Health in America.
Accessed September 9, 2020. Washington, D.C.: The National Academies Press; 2011.
25. Fleming E, Afful J. Prevalence of total and untreated Available at: “https://www.hrsa.gov/sites/default/files/
dental caries among youth: United States, 2015-2016. publichealth/clinical/oralhealth/advancingoralhealth.pdf ”.
NCHS Data Brief, no 307. Hyattsville, Md.: National Accessed November 11, 2020.
Center for Health Statistics; 2018:1-7. Available at:
“https://www.cdc.gov/nchs/data/databriefs/db307.pdf ”.
Accessed November 11, 2020.
26. Tabak LA, U.S. Department of Health and Human Ser-
vices National Institutes of Health. Notice to announce
commission of a Surgeon General’s report on oral health.
Federal Registry 2018;83(145):1. Available at: “https://
www.govinfo.gov/content/pkg/FR-2018-07-27/pdf/2018-
16096.pdf ”. Accessed September 9, 2020.

ORAL HEALTH POLICIES: DENTAL HOME
Policy on the Dental Home

Latest Revision How to Cite: American Academy of Pediatric Dentistry. Policy on the
2018 dental home. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2020:43-4.
Purpose Referral by the primary care physician or health provider has

The American Academy of Pediatric Dentistry (AAPD) been recommended, based on risk assessment, as early as six
supports the concept of a dental home for all infants, children, months of age and no later than 12 months of age.10-12 Fur-
adolescents, and persons with special health care needs. The thermore, subsequent periodicity of reappointment is based
dental home is inclusive of all aspects of oral health that result upon risk assessment. This provides time-critical opportunities
from the interaction of the patient, parents, dentists, dental to implement preventive health practices and reduce the
professionals, and nondental professionals. Establishment of child’s risk of preventable dental/oral disease.13
the dental home is initiated by the identification and interac-
tion of these individuals, resulting in a heightened awareness Policy statement
of all issues impacting the patient’s oral health.1 This concept The AAPD encourages parents and other care providers to
is derived from the American Academy of Pediatrics’ (AAP) help every child establish a dental home by 12 months of
definition of a medical home which is an approach to provid- age. The AAPD recognizes a dental home should provide:
ing comprehensive and high quality primary care and not a • comprehensive, continuous, accessible, family-
location or physical structure.2 centered, coordinated, compassionate, and culturally-
effective care for children, as modeled by the
Methods AAP.1,14
This policy was developed by the Council on Clinical Affairs • comprehensive evidence-base oral health care
and adopted in 2001. This document is an update from the including acute care and preventive services in
last revision in 2015. This policy is based on a review of the accordance with AAPD periodicity schedules.1,15
current dental and medical literature related to the establish- • comprehensive assessment for oral diseases and
ment of a dental home. An electronic search was conducted conditions.
using the terms: dental home, medical home in pediatrics, and • individualized preventive dental health program based
infant oral health care; fields: all fields: limits: within the last upon a caries-risk assessment 16 and a periodontal
10 years, humans, English. Papers for review were chosen from disease risk assessment12.
this list and from references within selected articles. Expert • anticipatory guidance regarding growth and dev-
opinions and best current practices were relied upon when elopment.15
clinical evidence was not available. • management of acute/chronic oral pain and infection.
• management of and long-term follow-up for acute
Background dental trauma.17-19
The AAP issued a policy statement defining the medical home • information about proper care of the child’s teeth
in 1992.3 Since that time, it has been shown that health care and gingivae, and other oral structures. This would
provided to patients in a medical home environment is more include the prevention, diagnosis, and treatment
effective and less costly in comparison to emergency care of disease of the supporting and surrounding tissues
facilities or hospitals.3-5 Strong clinical evidence exists for the and the maintenance of health, function, and
efficacy of early professional dental care complemented with esthetics of those structures and tissues.20
caries-risk and periodontal-risk assessment, anticipatory • dietary counseling.21
guidance, and periodic supervision.6 The establishment of • referrals to dental specialists when care cannot
a dental home follows the medical home model as a cost- directly be provided within the dental home.
effective measure to reduce the financial burden and decrease • education regarding future referral to a dentist knowl-
the number of dental treatment procedures experienced by edgeable and comfortable with adult oral health
young children.7,8 It also serves as a higher quality health care issues for continuing oral health care.
alternative in orofacial emergency care situations.9
Children who have a dental home are more likely to receive
ABBREVIATIONS
appropriate preventive and routine oral health care, thereby AAP: American Academy of Pediatrics. AAPD: American Academy
improving families’ oral health knowledge and practices, Pediatric Dentistry.
especially in children at high risk for early childhood caries.6

ORAL HEALTH POLICIES: DENTAL HOME
• recommendations and coordination of uninterrupted 13. U.S. Department of Health and Human Services.
comprehensive oral health care during the transition Healthy People 2020: Oral health of children and ado-
from adolescence to adulthood.14,22 lescents. Available at: “http://www.healthypeople.gov/
• referral, at an age determined by patient, parent, and 2020/topics-objectives/topic/oral-health/objectives”.
pediatric dentist, to a dentist knowledgeable and Accessed March 16, 2018.
comfortable with managing adult oral health care 14. American Academy of Pediatrics. Preamble to patient-
needs. centered medical home joint principles 2007. Available
at: “https://www.aap.org/en-us/professional-resources/
The AAPD advocates interaction with early intervention quality-improvement/_layouts/15/WopiFrame.aspx?
programs, schools, early childhood education and child care sourcedoc=/en-us/professional-resources/quality-
programs, members of the medical and dental communities, improvement/Documents/Preamble-Patient-Centered-
and other public and private community agencies to ensure Principles.doc&action=default”. Accessed March 1, 2018.
awareness of age-specific oral health issues.23 ®
org/6uEP86IxA”)
References 15. American Academy of Pediatric Dentistry. Periodicity
1. American Academy of Pediatric Dentistry. Definition of of examination, preventive dental services, anticipatory
dental home. Pediatr Dent 2018;40(6):12. guidance/counseling, and oral treatment for infants,
2. American Academy of Pediatrics. The medical home. children, and adolescents. Pediatr Dent 2018;40(6):
Pediatrics 2002;110(1Pt1):184-6. 194-204.
3. American Academy of Pediatrics Ad Hoc Task Force on 16. American Academy of Pediatric Dentistry. Caries-risk
the Definition of the Medical Home. The medical home. assessment and management for infants, children, and
Pediatrics 1992;90(5):774. adolescents. Pediatr Dent 2018;40(6):205-12.
4. American Academy of Pediatrics Council on Children 17. Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. In-
with Disabilities. Care coordination: Integrating health ternational Association of Dental Traumatology guide-
and related systems of care for children with special lines for the management of traumatic dental injuries:
health care needs. Pediatrics 2005;116(5):1238-44. 1. Fractures and luxations of permanent teeth. Dent
5. Klitzner TS, Rabbitt LA, Chang RK. Benefits of care Traumatol 2012;28(1):2-12. Erratum in Dent Traumatol
coordination for children with complex disease: A pilot 2012;28(6):499.
medical home project in a resident teaching clinic. J 18. Andersson L, Andreasen JO, Day P, et al. International
Pediatr 2010;156(6):1006-10. Association of Dental Traumatology guidelines for the
6. Thompson CL, McCann AL, Schneiderman ED. Does management of traumatic dental injuries: 2. Avulsion of
the Texas First Dental Home program improve parental permanent teeth. Dent Traumatol 2012;28(2):88-96.
oral care knowledge and practices? Pediatr Dent 2017;39 19. Malmgren B, Andreasen JO, Flores MT, et al. Interna-
(2):124-9. tional Association of Dental Traumatology guidelines
7. Nowak AJ, Casamassimo PS, Scott J, Moulton R. Do for the management of traumatic dental injuries: 3.
early dental visits reduce treatment and treatment costs Injuries in the primary dentition. Dent Traumatol 2012;
for children? Pediatr Dent 2014;36(7):489-93. 28(3):174-82.
8. Kolstad C, Zavras A, Yoon R. Cost-benefit analysis of 20. American Academy of Pediatric Dentistry. Policy on early
the age one dental visit for the privately insured. Pediatr childhood caries: Classifications, consequences and
Dent 2015;37(4):376-80. preventive strategies. Pediatr Dent 2018;40(6):60-2.
9. Allareddy V, Nalliah RP, Haque M, Johnson H, Tech 21. American Academy of Pediatric Dentistry. Policy on
SRB, Lee MK. Hospital-based emergency department dietary recommendations for infants, children and
visits with dental conditions among children in the adolescents. Pediatr Dent 2018;40(6):65-67.
United States: Nationwide epidemiological data. Pediatr 22. American Academy of Pediatric Dentistry. Policy on
Dent 2014;36(5):393-9. transitioning from a pediatric-centered to an adult-
10. Nowak AJ, Casamassimo PS. The dental home: A pri- centered dental home for individuals with special health
mary oral health concept. J Am Dent Assoc 2002;133 care needs. Pediatr Dent 2018;40(6):131-4.
(1):93-8. 23. American Academy of Pediatric Dentistry. Dental home
11. Casamassimo P, Holt K, eds. Bright Futures in Practice: resource center. Available at: “http://www.aapd.org/
Oral Health. Pocket Guide, 2nd ed. Washington, D.C.: advocacy/dentalhome/”. Accessed March 16, 2018.
National Maternal and Child Oral Health Resource
Center; 2014.
®
(Archived by WebCite at: “http://www.webcitation.org/
722MEzKg7”)
12. American Academy of Periodontology. Periodontal
diseases of children and adolescents. J Periodontol 2003;
74(11):1696-704.

ORAL HEALTH POLICIES: WORKFORCE ISSUES AND DELIVERY OF SERVICES
Policy on Workforce Issues and Delivery of Oral

Health Care Services in a Dental Home
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Policy on work-
2019 force issues and delivery of oral health care services in a dental home.
Purpose in poverty or low-income households and lack access to an

The American Academy of Pediatric Dentistry (AAPD) on-going source of quality dental care.2 Research on the topic
advocates optimal oral health and health care services for all has shown that the distribution of these disparities may vary
children, including those with special health care needs. Strate- by age group.3
gies for improving access to dental care, the most prevalent The mission of the AAPD is “to advance optimal oral
unmet health care need for disadvantaged U.S. children, and health for all children by delivering outstanding service that
increasing utilization of available services should include, but meets and exceeds the needs and expectations of our mem-
not be limited to, workforce considerations. This policy will bers, partners, and stakeholders.”4 AAPD has long focused
address workforce issues with an emphasis on the benefits of its efforts on addressing the disparities between children
oral health care services delivered within a dentist-directed who are at risk of having high rates of dental caries and the
dental home. millions of U.S. children who enjoy access to quality oral
health care and unprecedented levels of oral health. AAPD’s
Methods advocacy activities take place within the broader health
In 2008, the AAPD created a Task Force on Workforce Issues care community and with the public at local, regional, and
(TFWI) which was charged, in part, with investigating the national levels.
problem of access to oral health care services by children in Access to care issues extend beyond a shortage or mal-
the U.S. and analyzing the different auxiliary delivery sys- distribution of dentists or, more specifically, dentists who
tems available. The TFWI’s findings and recommendations treat Medicaid or State Children’s Health Insurance Program
were summarized in a report1 presented to the AAPD Board (CHIP) recipients. Health care professionals often elect to not
of Trustees in 2009. That report served as the basis for the participate as providers in these programs due to low reim-
original version of this policy, developed by the Council on bursement rates, administrative burdens, and the frequency of
Clinical Affairs and initially adopted in 2011. This document failed appointments by patients whose treatment is publicly
is an update of the 2014 revision. It includes an electronic funded.5-8 Nevertheless, American Dental Association (ADA)
®
search with PubMed /MEDLINE using the terms: pediatric survey data reveals that pediatric dentists report the highest
dentistry workforce, access to oral health care, disparities in percentage of patients insured through public assistance among
oral health care, non-dentist provider model, dental therapy all dentists.9 Medicaid-enrolled children living in areas with
model, expanded function dental assistants/auxiliaries, dental more pediatric dentists are more likely to utilize preventive
care delivery, dental workforce, oral health inequalities, access dental care.10 However, when considering the disincentives of
to dental care, and dental therapists. participating as Medicaid/CHIP providers, more dentists and/
or non-dentist oral health care providers cannot be considered
Background the panacea for oral health disparities.
Access to oral health care for children is an important concern Inequities in oral health can result from underutilization
that has received considerable attention since publication of of services. Lack of health literacy, limited English proficiency,
Oral Health in America: A Report of the Surgeon General in and cultural and societal barriers can lead to difficulties in
2000. 2 The report identified “profound and consequential utilizing available services. Financial circumstances, as well as
disparities in the oral health of our citizens” and that dental geographical and transportational considerations, also can
disease “restricts activities in school, work, and home, and
often significantly diminishes the quality of life.”2 It concluded
that for certain large groups of disadvantaged children there ABBREVIATIONS
is a “silent epidemic” of dental disease.2 This report identified AAP: American Academy of Pediatrics. AAPD: American Academy of
dental caries as the most common chronic disease of children Pediatric Dentistry. ADA: American Dental Association. CHIP: Chil-
dren’s Health Insurance Program. TFWI: Task Force on Workforce
in the U.S., noting that 80 percent of tooth decay is found Issues.
in 20 to 25 percent of children, large portions of whom live

impede access to care. Eliminating such barriers will require a education and coordination of oral health services. Utilizing
collaborative, multi-faceted approach.11,12 Systematic policy allied personnel to improve oral health literacy could decrease
and environmental changes that improve living conditions individuals’ risk for oral diseases and mitigate a later need for
and alleviate poverty are needed to directly address the social more extensive and expensive therapeutic services.
determinants of health. 13 All the while, stakeholders must In addition, advancing optimal oral health for all children
promote education and primary prevention so that disease through its policies, best practices, and clinical practice
levels and the need for therapeutic services decrease. guidelines, AAPD advocacy efforts, in part, include:
All AAPD advocacy efforts are based upon the organiza- 1. working closely with legislators, professional associations
tion’s strategic objectives.4 A major component of AAPD’s and health care professionals to implement research op-
advocacy efforts is development of oral health policies, best portunities in pediatric oral health and educate pediatric
practices, and evidence-based clinical practice guidelines 14 dentists, health care providers, and the public regarding
that promote access to and delivery of safe, high quality com- pediatric oral health.
prehensive oral health care for all children, including those 2. convening an annual Advocacy Conference in Washington,
with special health care needs, within a dental home. A dental D.C. to advocate for funding for pediatric and general
home is the ongoing relationship between the dentist and the dentistry residency programs and faculty loan repayment.
patient, inclusive of all aspects of oral health care delivery, in 3. working with the ADA to identify non-financial barriers
a comprehensive, continuously accessible, coordinated, and to oral health care and develop recommendations to
family-centered way.15 Such care takes into consideration the improve access to care for Medicaid recipients.25,26
patient’s age, developmental status, and psychosocial well- 4. partnering with federally-funded agencies to develop
being and is appropriate to the needs of the child and family. strategies to improve children’s oral health.27
This concept of a dental home was detailed in a 2001 AAPD 5. examining the various non-dentist (also known as mid-
oral health policy16 and is derived from the American Academy level) provider models that exist and/or are being
of Pediatrics’ (AAP) model of a medical home.17,18 The AAPD, proposed to address the access to care issues.28
AAP, ADA, and Academy of General Dentistry support the
establishment of a dental home as early as six months of age The AAPD TFWI reported that a number of provider
and no later than 12 months of age.14,18-20 This provides time- models to improve access to care for disadvantaged children
critical opportunities to provide education on preventive have been proposed and, in some cases, implemented follow-
health practices and reduce a child’s risk of preventable dental/ ing the Surgeon General’s report. 1 At the heart of the issue
oral disease when delivered within the context of an ongoing with each non-dentist provider proposal is ensuring ongoing
relationship. Prevention can be customized to an individual access to dental care for the underserved. Therefore, practice
child’s and/or family’s risk factors. Growing evidence supports location and retention of independent non-dentist providers
the effectiveness of early dental visits in reducing dental are important considerations. When providers are government
caries.21-23 Each child’s dental home should include the capacity employees (e.g., Indian Health Services, National Health
to refer to other dentists or medical care providers when all Services Corps), they are assigned to high-need areas. The
medically-necessary care cannot be provided within the dental dental therapy model has been shown to improve use of
home. The AAPD strongly believes a dental home is essential dental care services in Alaska.29,30 However, the current U.S.
for ensuring optimal oral health for all children.24 proposed models are private practice/non-government em-
Central to the dental home model is dentist-directed ployee models, providing no assurances that independent
care. The dentist performs the examination, diagnoses oral providers will locate in underserved areas. Recent case studies
conditions, and establishes a treatment plan that includes of private practices in Minnesota describe the impact of dental
preventive services, and all services are carried out under the therapists on production. Their findings suggest that while a
dentist’s supervision. The dental home delivery model implies therapist joining a dentist in a located practice may increase
direct supervision (i.e., physical presence during the provision the dentist’s efficiency, it does not expand geographic access
of care) of allied dental personnel by the dentist. The allied to dental care characteristic of the Alaska initiative or of the
dental personnel (e.g., dental hygienist, expanded function international model of therapists. 31-33 Moreover, evidence
dental assistant/auxiliary, dental assistant) work under direct from several developed countries that have initiated mid-level
supervision of the dentist to increase productivity and efficiency provider programs suggests that, when afforded an opportu-
while preserving quality of care. This model also allows for nity, those practitioners often gravitate toward private practice
provision of preventive oral health education and preventive settings in less-remote areas, thereby diminishing the impact
oral health services by allied dental personnel under general on care for the underserved.34
supervision (i.e., without the presence of the supervising In all existing and proposed non-dentist provider models,
dentist in the treatment facility) following the examination, the clinician receives abbreviated levels of education compared
diagnosis, and treatment plan by the licensed, supervising to the educational requirements of a dentist. For example, the
dentist. Furthermore, the dental team can be expanded to dental health aid therapist model in Alaska is a two-year certi-
include auxiliaries who go into the community to provide ficate program with a pre-requisite high school education.35,36

The level of educational training varies from state to for children up to 18 years of age, with most public primary
state,37-39 and none of the current programs is approved by schools having a dental clinic and many regions operating
the Commission on Dental Accreditation. In contrast, building mobile clinics.46 In New Zealand’s most recent nationwide
on their college education, dental students generally spend four oral health status survey, overall, one in two children aged
years learning the biological principles, diagnostic skills, and 2–17 years was caries-free. The caries rate for five-year-olds
clinical techniques to distinguish between health and disease and eight-year-olds in 2009 was 44.4 percent and 47.9 per-
and to manage oral conditions while taking into consideration a cent respectively.47 These caries rates, which are higher than
patient’s general health and well-being. The clinical care they the U.S., United Kingdom, and Australia, help refute a pre-
provide during their doctoral education is under direct super- sumption that utilization of non-dentist providers will
vision. Those who specialize in pediatric dentistry must spend overcome the disparities.
an additional 24 or more months in a full-time post-doctoral As technology continues to improve, proposed models may
program that provides advanced didactic and clinical experi- suggest dentist supervision of services outside the primary
ences.40 The skills that pediatric dentists develop are applied practice location via electronic communicative means to be
to the needs of children through their ever-changing stages comparable in safety and effectiveness to services provided
of dental, physical, and psychosocial development, treating under direct supervision by a dentist. Health care already has
conditions and diseases unique to growing individuals. witnessed benefits of electronic communications in diagnostic
While most pediatric dental patients can be managed effec- radiology and other consultative services. The AAPD encour-
tively using communicative behavioral guidance techniques, ages exploration of new models of dentist-directed health
many of the disadvantaged children who exhibit the greatest care services that will increase access to care for underserved
levels of dental disease require advanced techniques (e.g., populations. But as witnessed through the New Zealand oral
sedation, general anesthesia).41,42 Successful behavior guidance health survey, a multi-faceted approach will be necessary to
enables the oral health team to perform quality treatment safely improve the oral health status of our nation’s children.
and efficiently and to nurture a positive dental attitude in the
pediatric patient.43 Accurate diagnosis of behavior and safe Policy statement
and effective implementation of advanced behavior guidance The American Academy of Pediatric Dentistry remains com-
techniques necessitate specialized knowledge and experience. mitted in its vision and mission to address the disparities
Studies addressing the technical quality of restorative pro- between children who lack access to quality oral health care
cedures performed by non-dentist providers have found, in and those who benefit from such services. AAPD believes that
general, that within the scope of services and circumstances all infants, children, and adolescents, including those with
to which their practices are limited, the technical quality is special health care needs, deserve access to high quality com-
comparable to that produced by dentists.44,45 There is, how- prehensive preventive and therapeutic oral health care services
ever, no evidence to suggest that they deliver any expertise provided through a dentist-directed dental home. In the delivery
comparable to a dentist in the fields of diagnosis, pathology, of all dental care, patient safety must be of paramount concern.
trauma care, pharmacology, behavioral guidance, treatment AAPD encourages the greater use of expanded function
plan development, and care of patients with special health care dental assistants/auxiliaries and dental hygienists under direct
needs. It is essential that policy makers recognize that evalua- supervision by a dentist to help increase volume of services
tions which demonstrate comparable levels of technical quality provided within a dental home, based upon their proven effec-
merely indicate that individuals know how to provide certain tiveness and efficiency in a wide range of settings.45-51 The
limited services, not that those providers have the knowledge AAPD also supports provision of preventive oral health services
and experience necessary to determine whether and when by a dental hygienist under general supervision (i.e., without
various procedures should be performed or to manage the presence of the supervising dentist in the treatment facility)
individuals’ comprehensive oral health care, especially with following the examination, diagnosis, and treatment plan by
concurrent conditions that may complicate treatment or have the licensed, supervising dentist. Similarly, partnering with
implications for overall health. Technical competence cannot other health providers, especially those who most often see
be equated with long-term outcomes. children during the first years of life (e.g., pediatricians, family
The AAPD continues to work diligently to ensure that the physicians, pediatric nurses), will expand efforts for improving
dental home is recognized as the foundation for delivering children’s oral health.
oral health care of the highest quality to infants, children, and The AAPD strongly believes there should not be a two-
adolescents, including those with special health care needs. tiered standard of care, with our nation’s most vulnerable
The AAPD envisions that many new and varied delivery models children receiving services by providers with less education and
will be proposed to meet increasing demands on the infra- experience. AAPD will continue its efforts to:
structure of existing oral health care services in the U.S. New 1. educate families, health care providers, academicians,
Zealand, known for utilizing dental therapists since the 1920’s community leaders, and partnered governmental agen-
and frequently referenced as a workforce model for consid- cies on the benefits of early establishment of a dental
eration in the U.S., makes dental care available at no cost home.

2. forge alliances with legislative leaders that will advance 9. American Dental Association. 2009 Survey of Dental
the dental home concept and improve funding for Fees. Chicago, Ill.: American Dental Association;
delivery of oral health care services and dental education. September, 2009.
3. expand public-private partnerships to improve the oral 10. Heidenreich JF, Kim AS, Scott JM, Chi DL. Pediatric
health of children who suffer disproportionately from dentistry and preventive care utilization for Medicaid
oral diseases. children. Pediatr Dent 2015;37(4):371-5.
4. encourage recruitment of qualified students from rural 11. American Dental Association. Breaking down barriers to
areas and underrepresented minorities into the dental oral health for all Americans: The role of workforce. A
profession. statement from the American Dental Association.
5. partner with other dental and medical organizations to February 22, 2011. Available at: “http://www.ada.org/en/
study barriers to care and underutilization of available ~/media/ADA/Advocacy/Files/ada_workforce_statement”.
services. Accessed October 11, 2017. (Archived by WebCite at: ®
6. support scientific research on safe, efficacious, and sus- “http://www.webcitation.org/6u8YZdCzo”)
tainable models of delivery of dentist-directed pediatric 12. Academy of General Dentistry. White paper on increas-
oral health care that is consistent with AAPD’s oral ing access to and utilization of oral health care services.
health policies and clinical practice guidelines. Available at: “https://www.agd.org/docs/default-source/
advocacy-papers/agd-white-paper-increasing-access-to
Furthermore, AAPD encourages researchers and policy -and-utilization-of-oral-health-care-services.pdf?sfvrsn
makers to consult with AAPD and its state units in the devel-
opment of pilot programs and policies that have potential for
=2”. Accessed July 13, 2019. (Archived by WebCite at:
“http://www.webcitation.org/6u8lmvj7N”)
®
significant impact in the delivery of oral health care services 13. American Academy of Pediatric Dentistry. Policy on
for our nation’s children. social determinants of children’s oral health and health
disparities. Pediatr Dent 2018;40(6):23-6.
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ORAL HEALTH POLICIES: CHILD ID PROGRAMS
Policy on Child Identification Programs

Latest Revision How to Cite: American Academy of Pediatric Dentistry. Policy on child
2017 identification programs. The Reference Manual of Pediatric Dentistry.
Purpose DNA from blood, saliva, and other tissue.10 Some of these
The American Academy of Pediatric Dentistry (AAPD), nondental sources have practical limitations. Few children have
recognizing the role that dental records play in forensic identi- fingerprint records. DNA sampling, while being state of the
fication, encourages dental practitioners and administrators of art, can be difficult to access as well as protracted and costly.11
child identification programs to implement simple practices Dentists can provide data without many of these limitations.
that can aid in identification of unknown infants, children, Many programs have been developed and sponsored
and adolescents. The AAPD recommends that parents establish by community groups that use various child identification
a dental home, where clinical data is gathered, stored, and methods. Examples are:
updated routinely and can be made available to assist in • Child Identification Program (CHIP), sponsored by the
identification of missing and/or abducted persons. Masons. This program gathers a physical description and
features care, fingerprint cared or scanned print, several
Methods still photos of various profiles, a video recording or man-
This document was developed by the Council on Clinical nerisms with voice interview, and various DNA samples
Affairs and adopted in 2003. The last revision occurred in collected on dental impressions and/or cheek swabs.12
2008 and was reaffirmed in 2012. This policy revision in- • The National Child Identification Program, sponsored
®
cluded a new literature search of the PubMed /MEDLINE by the American Football Coaches Association with the
Optimist International and Clear Channel Int. They
electronic database using the terms: child, forensic, dental,
and identification; fields: all; limits: within the last 10 years, provide an identification kit which includes an inkless
English. One hundred twenty nine articles matched these fingerprinting card, DNA collection envelope, and cut
criteria. Papers for review were chosen from this list and from out wallet card.13,14
references within selected articles. When information from • New England Kids Identification System (KIDS) spon-
these articles did not appear sufficient or was inconclusive, sored by the Massachusetts Free Masons and the Mas-
policies were based upon expert and/or consensus opinion sachusetts Dental Society, which incorporates dental bite
by experienced researchers and clinicians. impression and cheek swabs to gather DNA material
into the CHIP events.12,15,16
Background • The Federal Bureau of Investigation (FBI) has a free
More than 800,000 children in America are reported missing mobile telephone application (app) “FBI Child ID”,
each year.1 Since the passage of the Missing Children Act in available for download on both iTunes and Google Play.
1982 and the creation of the National Crime Information This application provides an easily accessible means to
Center, the dental profession has provided much of the infor- electronically store photos and vital information about
mation used to compare missing persons with unidentified children. Additionally, there is a special tab on the app
individuals.2,3 The Manual on Forensic Odontology utilized that allows quick and easily access to e-mail to send
by the American Society of Forensic Odontology demonstrates information to authorities, if necessary.17
the vital role of dentistry in identification of missing and
unknown persons.3 Numerous cases have been published in Policy statement
which law enforcement agencies called upon dentistry to The AAPD recognizes the importance of dentistry’s role in the
provide information that proved vital to the identification provision of data for identification of missing and/or deceased
process.4,5 Dental records used for identification purposes have children and encourages dental professionals to assist in iden-
included dental radiographs, facial photographs, study casts, tifying such individuals through dental records and other
dental examinations documenting teeth present and distin- mechanisms. The AAPD also encourages community identifi-
guishing features of oral structures, and histories documenting cation programs to include a dental component documenting
appliances (prosthetic and orthodontic) in place, orthodontic
treatment, restored surfaces and materials used, and bite
registrations.6-9 ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. CHIP: Child
Nondental sources of distinguishing information currently Identification Program. FBI: Federal Bureau of Investigation.
include fingerprints, photographs, physical descriptions, and

ORAL HEALTH POLICIES: CHILD ID PROGRAMS
the child’s dental home18 and encouraging consistent dental 11. Aidar M, Line SR. A simple and cost-effective protocol
visits. A dental home should be established for every child for DNA isolation from buccal epithelial cells. Braz Dent
by 12 months of age.18,19 A detailed dental record, updated at J 2007;18(2):148-52.
recall appointments, economically establishes an excellent 12. Masonic Youth Child Identification Program (MYCHIP).
database of confidential, state-of-the-art child identification Available at: “http://www.mychip.org”. Accessed June
information that can be retrieved easily, stored safely, and up-
dated periodically. The dental record may contain a thorough
®
10, 2017. (Archived by WebCite at: “http://www.web
citation.org/6o4uW4HhZ”)
description of the oral cavity documenting all anomalies, a 13. National Child Identification Program. The ID Kit.
record of restorative care delivered including materials used, Available at: “http://www.childidprogram.com/the-id-
appropriate dental radiographs,20 photographs, study casts, and
bite registration.
®
kit”. Accessed June 10, 2017. (Archived by WebCite at:
“http://www.webcitation.org/6o4utJUUU”)
14. National Child Identification Program. Swab Instruc-
References tions. Available at: “http://www.childidprogram.com/
1. National Child Identification Program. Why should we the-id-kit/swab-instructions”. Accessed June 10, 2017.
fingerprint our children? National Child Identification
Program. About us. Available at: “http://www.childid /6o4ujbJKe”)
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Windsor LJ. An evaluation of DNA yield, DNA quality
and bite registration from a dental impression wafer. J
2. Sperber N. Identification of children and adults through Am Dent Assoc 2007;138(9):1234-40.
federal and state identification systems: Recognition of 16. Tesini DA, Harte DB. Anatomy of a properly taken
human bite marks. Forensic Sci Int 1986;30(2-3):187-93. toothprint thermoplastic bite impression. J Mass Dent
3. Kavanaugh SA, Filippi JE. Missing and unidentified Soc 2005;54(2):22.
persons. In: Senn DR, Weems RA, eds. Manual of Fo- 17. Federal Bureau of Investigation. The FBI’s Child ID app
rensic Odontology. 5th ed. Boca Raton, Fla.: CRC Press; putting safety in your hands. Available at “https://www.
2013:195. fbi.gov/file-repository/child-id-app-full-content.pdf.”
4. Chen H, Jain AK. Automatic forensic dental identifica-
tion. In: Jain AK, Flynn P, Ross AA, eds. Handbook of
Accessed June 10, 2017. (Archived by WebCite at:
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Biometrics. New York, N.Y.: Springer Science+Business 18. American Academy of Pediatric Dentistry. Policy on the
Media, LLC; 2008:231-51. dental home. Pediatr Dent 2016;38(special issue):25-6.
5. Debnath N, Gupta R, Nongthombam RS, Chandran
P. Forensic odontology. J Med Soc 2016;30(1):20-3.
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6. Cardoza AR, Wood JD. Atypical forensic dental 19. American Academy of Pediatric Dentistry. Guideline
identifications. J Calif Dent Assoc 2015;43(6):303-8. on perinatal and infant oral health care. Pediatr Dent
7. Berman GM, Bush MA, Bush PI, Freeman AJ, et al. 2016;38(special issue):150-4. Accessed June 10, 2017.
Dental identification. In: Senn DR, Weems RA, eds.
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Fla.: CRC Press; 2013:75-127. 20. American Dental Association, U.S. Department of Health
8. Shanbhag VK. Significance of dental records in personal and Human Services. Dental radiographic examinations:
identification in forensic sciences. J Forensic Sci Med Recommendations for patient selection and limiting
2016;2(1):39-43. radiation exposure. Rockville, Md.: Food and Drug
9. Reddy G, Reddy VP, Sharma M, Aggarwal M. Role of Administration; 2012. Available at: “http://www.fda.gov
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10. Conceição L, da Silveira IA, Lund RG. Forensic dentistry: MedicalX-Rays/UCM329746.pdf ”. Accessed June 10,
An overview of the human identification’s techniques
of this dental specialty. J Forensic Res 2015;6(1):1. tion.org/6tHkUmUn3”)
®

ORAL HEALTH POLICIES: ORAL HEALTH IN CHILD CARE CENTERS
Policy on Oral Health in Child Care Centers

Latest Reaffirmation How to Cite: American Academy of Pediatric Dentistry. Policy on oral
2020 health in child care centers. The Reference Manual of Pediatric Dentistry.
Purpose states developed nutritional regulations on the frequency of

The American Academy of Pediatric Dentistry (AAPD) providing snacks and meals at child care centers.6 In con-
recognizes that one out of three preschool age children receives trast, oral health practices were not well addressed, as
care in a child care center.1 The expectation is that this policy demonstrated by limited regulations highlighting prevention
will provide guidance to the child care centers, pediatric of early childhood caries (ECC).6 In one state, there were
dentists, other health care professionals, legislators, and policy found to be variations in some oral health practices between
makers regarding oral health activities and oral health pro- centers serving children of lower socioeconomic status and
motion in out-of-home child care settings. those providing care to higher socioeconomic status children.7
In comparison of state-funded and non-state-funded child
Methods care centers, the researcher found non-state-funded centers
This policy was developed by the Council of Clinical Affairs were more inclined to implement oral health practices.7 A
and adopted in 2011. This document is a reaffirmation of the higher percentage of state-funded childcare centers reported
updated version, revised in 2016. The revision was based upon tooth brushing as a routine activity in the classroom, whereas
a review of current dental and medical literature, including a a higher percentage of non-state funded centers reported
®
search of the PubMed /MEDLINE database using the terms:
oral health care guidelines in child care centers, child daycare
having implemented numerous oral health practices as well
as an educational practice focusing on oral health.7 Many
centers and dental health, dental guidelines and daycare centers, organizations have requirements and recommendations that
and dental care in child day care centers; fields: all; limits: apply to out-of-home child care. The American Academy of
within the last 10 years, humans, English, birth through age Pediatrics, the American Public Health Association, the
18. Twenty-two articles matched these criteria. Papers for National Association for the Education of Young Children
review were chosen from this list and from the references (NAEYC), and Head Start are some of the organizations that
within selected articles. When data did not appear sufficient address oral health in out-of-home child care.8-10 They are
or were inconclusive, policies were based upon expert and/or valuable resources, as are many state publications.
consensus opinion by experienced researchers and clinicians. Effective oral health care requires collaboration between
Documents of health care and public policy organizations, families, early care and educational professionals, and health
state statutes, and regulations relating to the concept of oral care professionals. Collaboration has the potential to improve
health in child care centers also were reviewed. the breadth and effectiveness of health promotion education4
and enhance the opportunity for a child to have a lifetime
Background free from preventable oral disease. Establishment of a dental
In the U.S. in 2011, 61 percent of children ages zero through home by 12 months of age ensures awareness of age-specific
five received some form of child care arrangement on a regular oral health issues with long term positive effects for the chil-
basis from persons other than their parents.1 Fifty-five to 65 dren.11 Caries is a significant public health problem affecting
percent of these children attended center-based programs pre-school children.12 It is the most common chronic disease
which include day care centers, pre-kindergartens, nursery of childhood, affecting 28 percent of children two to five
schools, Head Start programs, and other early childhood edu- years of age, or over four million children nationwide.13 By
cation programs.2,3 the time they begin kindergarten, 40 percent of children have
Parents, directors of child care centers, and health profes- caries.14 Epidemiologic data from a 2011-2012 national survey
sionals believe that enhancing health promotion education in clearly indicates that ECC remains highly prevalent in poor
child care could improve child health.4 It is important that and near poor U.S. preschool children.15 The prevalence of
the oral health needs of infants and young children be ad- caries within the two to five year old age group among
dressed as early as possible and as a part of well-child care since
dental disease is preventable. Currently, a majority of states
address oral health in their child care licensing regulations.5-7
ABBREVIATIONS
However, a majority of states’ oral health regulations in early AAPD: American Academy Pediatric Dentistry. ECC: Early child-
education and child care center programs do not provide hood caries.
comprehensive oral health policies and practices.5 Forty-six

higher-income families was 18 percent, while that of children • incorporate an oral health assessment as part of the daily
from low-income families was 42 percent.16,17 Low-income health check of each child.
children are affected disproportionately; 80 percent of tooth • promote supervised or assisted oral hygiene practices at
decay is found in 20 to 25 percent of children, large portions least once daily after a meal or a snack.
of whom live in poverty or low income households.18 Dental • provide well-balanced and nutrient-dense diets of low
care is the greatest unmet need for children.19 caries-risk.20
• have clean, optimally-fluoridated drinking water available
Policy statement for consumption throughout the day.21
The AAPD encourages child care centers, early education pro- • not permit infants and toddlers to have bottles/sippy cups
viders, and parents to implement preventive practices that in the crib or to carry them while walking or crawling
can decrease a child’s risk of developing ECC.12 The AAPD while under the child care center’s supervision.
recognizes that increasing health promotion in out-of-home • minimize saliva-sharing activities (e.g., sharing utensils,
child care settings could improve the oral health of millions orally cleansing a pacifier) to help decrease an infant’s or
of pre-school age children. Therefore, the AAPD encourages toddler’s acquisition of cariogenic microbes.22
child care centers to: • consider implementation of comprehensive oral health
• utilize oral health consultation, preferably by a pediatric practices when legislative regulations are limited or non-
dentist, at least once a year and as needed. The health existent.7
consultant should review and observe program practices
regarding oral health and make individualized recom- References
mendations for each program. 1. Laughlin L. Who’s minding the kids? Child care arrange-
• promote the concept of the dental home by educating ments: Spring 2011. Current Population Reports, P70-135,
their personnel as well as the parents on the importance U.S. Census Bureau, Washington, D.C.; 2013. Available
of oral health and providing assistance with establishment at: “https://www.census.gov/prod/2013pubs/p70-135.pdf ”.
of a dental home no later than 12 months of age of the Accessed June 15, 2016.
child. 2. The Federal Interagency Forum on Child and Family
• maintain a dental record, starting at age 12 months with Statistics (Forum), America’s Children in Brief: Key
yearly updates, as part of the child’s health report. It National Indicators of Well-Being 2010. Available at:
should address the child’s oral health needs including “http://www.childstats.gov/pdf/ac2010/ac_10.pdf ”.
any special instructions given to the caregivers. Accessed June 15, 2016.
• have written, up-to-date, comprehensive procedures to 3. Organisation for Economic Co-operation and Develop-
prepare for, report, and respond to medical and dental ment. Enrolment in childcare and pre-school. Available
emergencies. The source of urgent care should be known at: “http://www.oecd.org/els/soc/PF3_2_Enrolment_child
to caregivers and acceptable to parents. care_preschool.pdf ”. Accessed June 15, 2016.
• sponsor on-site, age-appropriate oral health education 4. Gupta RS, Shuman S, Taveras EM, Kulldorff M,
programs for the children that will promote good oral Finkelstein JA. Opportunities for health promotion edu-
hygiene and dietary practices, injury prevention, and the cation in child care. Pediatrics 2005;116(4):e499-e505.
importance of regularly scheduled dental visits. 5. Kranz AM, Rozier RG. Oral health content of early
• provide in-service training programs for personnel regard- education and child care regulations and standards. J
ing oral hygiene concepts, proper nutrition choices, Public Health Dent 2011;71(2):81-90.
link between diet and tooth decay, prevention of ECC, 6. Kim J, Kaste LM, Fadavi S, Benjamin Neelon SE. Are state
and children’s oral health issues including proper initial child care regulations meeting national oral health and
response to traumatic injuries along with dental conse- nutritional standards? Pediatr Dent 2012;34(4):317-24.
quences. Personnel with an understanding of these 7. Scheunemann D, Schwab M, Margaritis V. Oral health
concepts are at a great advantage in caring for children. practices of state and non-state funded licensed child care
• encourage parents to be active partners in their children’s centers in Wisconsin, USA. J Int Soc Prev Community
health care process and provide an individualized educa- Dent 2015;5(4):296-301.
tion plan, one that is sensitive to cultural values and 8. American Academy of Pediatrics, American Public Health
beliefs, to meet every family’s needs. Written material Association, and National Resource Center for Health and
should be available and, at a minimum, address oral Safety in Child Care and Early Education. 2011 Caring
health promotion and disease prevention and the timing for Our Children: National Health and Safety Performance
of dental visits. Standards; Guidelines for Early Care and Education Pro-
• familiarize parents with the use of and rationale for oral grams, 3rd ed. Elk Grove Village, Ill.: American Academy
health procedures administered through the program and of Pediatrics; Washington, D.C.: American Public Health
obtain advance parental authorization for such procedures. Association. Available at: “https://nrckids.org/files/
CFOC3_updated_final.pdf ”. Accessed June 15, 2016.

9. National Association for the Education of Young 15. Dye BA, Hsu KL, Afful J. Prevalence and measurement
Children. NAEYC Early Childhood Program Standards of dental caries in young children. Pediatr Dent 2015;
and Accreditation Criteria & Guidance for Assessment. 37(3):200-16.
Washington, D.C.: National Association for the Edu- 16. Dye BA, Arevalo O, Vargas CM. Trends in paediatric
cation of Young Children; 2015. Available at: “http:// dental caries by poverty status in the United States,
www.naeyc.org/files/academy/file/AllCriteriaDocument. 1988-1994 and 1999-2004. Int J Paediatr Dent 2010;20
pdf ”. Accessed June 30, 2016. (2):132-43.
10. Office of Human Development, U.S. Department of 17. Douglass JM, Clark MB. Integrating oral health into
Health and Human Services. Head Start Program Per- overall health care to prevent early childhood caries:
formance Standards & Other Regulations (45 CFR Parts Need, evidence, and solutions. Pediatr Dent 2015;37(3):
1301-1311). Available at: “http://eclkc.ohs.acf.hhs.gov/ 266-74.
hslc/standards/hspps/45-cfr-chapter-xiii/45-cfr-chap-xiii 18. U.S. Department of Health and Human Services. Oral
-eng.pdf ”. Accessed June 15, 2016. Health in America: A Report of the Surgeon General.
11. American Academy of Pediatric Dentistry. Policy on the Rockville, Md.: U.S. Department of Health and Human
dental home. Pediatr Dent 2016;38(special issue):25-6. Services. National Institute of Dental and Craniofacial
12. American Academy of Pediatric Dentistry. Policy on early Research, National Institutes of Health; 2000.
childhood caries (ECC): Classifications, consequences, 19. Newacheck P, Hughes D, Hung Y, Wong S, Stoddard J.
and preventive strategies. Pediatr Dent 2016;38(special The unmet health needs of America’s children. Pediatrics
issue):52-4. 2000;105(4):989-97.
13. Dye BA, Tan S, Smith V, Lewis BG, et al. Trends in oral 20. American Academy of Pediatric Dentistry. Policy on
health status. United States, 1988-1994 and 1999-2004. dietary recommendations for infants, children, and
National Center for Health Statistics. Vital Health Stat adolescents. Pediatr Dent 2016;38(special issue):57-9.
2007;11(248):1-92. 21. American Academy of Pediatric Dentistry. Policy on use
14. Pierce KM, Rozier RG, Vann WF. Accuracy of pediatric of fluoride. Pediatr Dent 2016;38(special issue):45-6.
primary care providers’ screening and referral for early 22. Berkowitz RJ. Mutans streptococci: Acquisition and
childhood caries. Pediatrics 2002;109(5):E82. Available transmission. Pediatr Dent 2006;28(2):106-9.
at: “http://pediatrics.aappublications.org/content/109/5/
e82.long”. Accessed June 15, 2016.

ORAL HEALTH POLICIES: SCHOOL-ENTRANCE ORAL HEALTH EXAMS
Policy on Mandatory School-Entrance Oral Health

Examinations
2017 mandatory school-entrance oral health examinations. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
Purpose for young children, affecting 23 percent of children two to

The American Academy of Pediatric Dentistry (AAPD) five years of age nationwide.5 By six to eight years of age,
encourages policy makers, public health and education officials, the prevalence of dental caries increases to 56 percent.5 Low-
and medical and dental communities to recognize that unmet income children are disproportionally affected, with 33 percent
oral health needs can impact a child’s ability to learn. An oral of low-income children experiencing 75 percent of dental
health examination prior to matriculation into school may caries.7 Dental care remains as one of the greatest unmet needs
improve school readiness by providing a timely opportunity for children. 8 Safe and effective measures exist to prevent
for prevention, diagnosis, and treatment of oral conditions. caries and periodontal diseases; however, dissemination and
awareness of such measures do not reach the population at
Methods large.1 More than one-third of the population of the United
This policy was developed by the Council on Clinical Affairs States does not benefit from community water fluoridation.9
and adopted in 2003. This document is an update of the Because the use of fluoride contributes to the prevention, inhi-
previous version, revised in 2012. This revision included bition, and reversal of caries,10 early determination of a child’s
electronic database and hand searches of articles in the systemic and topical fluoride exposure is important. A dental
medical and dental literature using the terms: oral health home provides the necessary diagnostic, preventive, and
examination, dental screening, dental examination, dental therapeutic practices, as well as ongoing risk assessment and
assessment, school oral health examinations, dental certificates education, to improve and maintain the oral health of infants,
AND school-entrance; fields: all; limits: within the last 10 children, and adolescents. 11 To maximize effectiveness, the
years, humans, English, birth through age 18. Additionally, dental home should be established within six months of
the U.S. Surgeon General’s report Oral Health in America 1 eruption of a child’s first tooth and no later than his/her first
and websites for the American Academy of Pediatrics and birthday.2
AAPD were referenced. The public’s lack of awareness of the importance of oral
health is a major barrier to dental care.1 Oral health is integral
Background to general health.1 Oral conditions can interfere with eating
Professional care is necessary to maintain oral health.1 The and adequate nutritional intake, speaking, self-esteem, and
AAPD “emphasizes the importance of initiating professional daily activities.12 Children with ECC may be severely under-
oral health intervention in infancy and continuing through weight because of associated pain and the disinclination to eat.
adolescence and beyond. The periodicity of professional oral Nutritional deficiencies during childhood can impact cognitive
health intervention and services is based on a patient’s indi- development.12,13 Rampant caries is one of the factors caus-
vidual needs and risk indicators.”2 The American Academy of ing insufficient development in children who have no other
Pediatrics recommends that, beginning at age three, a child’s medical problems.14 Unrecognized disease and postponed care
comprehensive health assessment should include attention to result in exacerbated problems, which lead to more extensive
problems that might influence school achievement.3 General and costly treatment needs. The World Health Organization
health examinations prior to school entrance are mandated by has suggested that school dental screenings could enable
many states. However, integration of general health and oral early recognition and timely interventions, leading to savings
health care programs remains deficient.4 In the U.S., approxi- of health care dollars for individuals, community health care
mately 23 percent of children aged 2-5 have dental caries in programs, and third-party payors.15
the primary dentition.5 Only 30 percent of schools conduct
oral health screenings once the child has matriculated.6 While
regulations may not guarantee that every child will be
examined by a dentist, they do increase the likelihood of this ABBREVIATIONS
happening. AAPD: American Academy Pediatric Dentistry. ECC: Early child-
Caries is the most common chronic disease of childhood hood caries.
in the U.S.1 Early childhood caries (ECC) is a severe problem

In 2000, the National Association of State Boards of Educa- health and school readiness for all children, and address
tion recognized “health and success in school are interrelated. related issues such as barriers to oral health care.
Schools cannot achieve their primary mission of education if • recognizes that without requiring, tracking, and funding
students and staff are not healthy and fit physically, mentally, appropriate follow-up care, requiring oral health exam-
and socially.”16 Children with dental pain may be irritable, inations is insufficient to ensure school readiness.
withdrawn, or unable to concentrate. Pain can affect test per- • encourages local leaders to establish a referral system to
formance as well as school attendance.12,13 Data from the North help parents obtain needed oral health care for their
Carolina Child Health Assessment and Monitoring Program children.
showed that children with poor oral health status were nearly • opposes regulations that would prevent a child from
three times more likely to miss school as a result of dental pain attending school due to noncompliance with mandated
than were their counterparts.17 In addition, absences caused by examinations.
pain were associated with poorer school performance.17 Further • encourages its members and the dental community at
analysis demonstrated that oral health status was associated large to volunteer in programs for school-entry dental
with performance independent of absence related to pain.17 examinations to benefit the oral and general health of
Following a report by the U.S. Surgeon General, 1 the the pediatric community.
Centers for Disease Control and Prevention launched the Oral
Health Program Strategic Plan for 2011-2014.18 This campaign References
aimed to provide leadership to prevent and control oral di- 1. U.S. Department of Health and Human Services. Oral
seases at national level. The program helped individual states Health in America: A Report of the Surgeon General.
strengthen their oral health promotion and disease prevention Rockville, Md.: U.S. Department of Health and Human
programs. However, requirements for oral health exam- Services, National Institute of Dental and Craniofacial
inations, implementation/enforcement of regulations, and Research, National Institutes of Health; 2000.
administrative disposition of collected data vary both among 2. American Academy of Pediatric Dentistry. Periodicity of
and within states.18 examination, preventive dental services, anticipatory
guidance, and oral treatment for children. Pediatr Dent
Policy statement 2017;39(6):188-96.
Early detection and management of oral conditions can im- 3. American Academy of Pediatrics. School health assess-
prove a child’s oral health, general health and well-being, and ment. Pediatrics 2000;105(4Pt1):8757. Reaffirmed
school readiness. Recognizing the relationship between oral October, 2011.
health and education, the AAPD: 4. Institute of Medicine, National Research Council. Im-
• supports legislation mandating a comprehensive oral proving Access to Oral Health Care for Vulnerable and
health examination by a qualified dentist for every stu- Underserved Populations. Washington, D.C.: The National
dent prior to matriculation into school. The examination Academies Press; 2011. Available at: “https://www.hrsa.
should be performed in sufficient detail to provide gov/publichealth/clinical/oralhealth/improvingaccess.
meaningful information to a consulting dentist and/or pdf ”. Accessed June 30, 2017. (Archived by WebCite®
public health officials. This would include documen- at: “http://www.webcitation.org/6ta8K4f9D”)
tation of oral health history, soft tissue health/pathologic 5. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental
conditions, oral hygiene level, variations from a normal Caries and Sealant Prevalence in Children and Adoles-
eruption/exfoliation pattern, dental dysmorphology or cents in the United States, 2011–2012. NCHS data brief,
discoloration, dental caries (including white-spot lesions), No. 191. Hyattsville, Md.: National Center for Health
and existing restorations. The examination also should Statistics. 2015. Available at: “https://www.cdc.gov/nchs/
provide an educational experience for both the child and products/databriefs/db191.htm”. Accessed June 11, 2017.
the parent. The child/parent dyad should be made aware (Archived by WebCite® at: “http://www.webcitation.org/
of age-related caries-risk and caries-protective factors, as 6ta8Q47bZ”)
well as the benefits of a dental home. 6. Centers for Disease Control and Prevention. Results from
• supports such legislation to include subsequent compre- the School Health Policies and Practices Study 2014.
hensive oral examinations at periodic intervals throughout Available at: “http://www.cdc.gov/healthyyouth/data/shp
the educational process because a child’s risk for ps/pdf/shpps-508-final_101315.pdf ”. Accessed February
developing dental disease changes and oral diseases are 23, 2017. (Archived by WebCite® at: “http://www.web
cumulative and progressive. citation.org/6oVC70IDq”)
• encourages state and local public health and education 7. Fisher-Owens SA, Barker JC, Adams S, et al. Giving
officials, along with other stake-holders such as health policy some teeth: Routes to reducing disparities in oral
care providers and dental/medical organizations, to doc- health. Health Aff (Millwood) 2008;27(2):404-12.
ument oral health needs, work toward improved oral

8. Bloom B, Jones LI, Freeman G. Summary health statistics 14. Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of
for U.S. children: National Health Interview Survey, nursing caries on body weight in a pediatric population.
2012. National Center for Health Statistics. Vital Health Pediatr Dent 1992;14(5):302-5.
Stat 2013;10(258):1-81. 15. Kwan S, Petersen PE. Oral health promotion: An Essen-
9. Centers for Disease Control and Prevention. Community tial Element of a Health-promoting School. In: World
Water Fluoridation. Fluoridation Statistics 2014. Avail- Health Organization Information Series on School
able at: “http://www.cdc.gov/fluoridation/statistics/2014 Health. Geneva, Switzerland: WHO; 2003:Document 11.
stats.htm”. Accessed February 23, 2017. (Archived by Available at: “www.who.int/oral_health/publications/doc
WebCite® at: “http://www.webcitationorg/6oVCcAbUU”) 11/en/”. Accessed August 7, 2017. (Archived by WebCite®
10. Centers for Disease Control and Prevention. Recommen- at: “http://www.webcitation.org/6siiOfHyI”)
dations for using fluoride to prevent and control dental 16. Bogden JF, Vega-Matos CA. Fit, healthy, and ready to
caries in the United States. MMWR Recomm Rep 2001; learn: A school health policy guide, part 1: Physical
50(RR14):1-42. activity, healthy eating, and tobacco-use prevention.
11. American Academy of Pediatric Dentistry. Policy on the Alexandria, Va.: National Association of State Boards of
dental home. Pediatr Dent 2017;39(special issue):29-30. Education; 2000.
12. Moynihan P, Petersen PE. Diet, nutrition and the preven- 17. Jackson SL, Vann WF, Kotch JB, Pahel BT, Lee JY. Impact
tion of dental diseases. Public Health Nutr 2004;7(1A): of poor oral health on children’s school attendance and
201-26. performance. Am J Public Health 2011;101(10):1900-6.
13. Nyaradi A, Li J, Hickling S, Foster J, Oddy WH. The role 18. Centers for Disease Control and Prevention. Oral Health
of nutrition in children’s neurocognitive development, Program. Strategic Plan 2011-2014. Available at: “https:
from pregnancy through childhood. Front Hum Neurosci //www.cdc.gov/oralhealth/pdfs/oral_health_strategic_
2013;7:97. Available at: “https://doi.org/10.3389/fnhum. plan.pdf ”. Accessed February 23, 2017. (Archived by
2013.00097”. Accessed June 7, 2017. (Archived by Web- WebCite® at: “http://www.webcitation.org/6oVCsiIKC”)
Cite® at: “http://www.webcitation.org/6siiqwGXO”)

ORAL HEALTH POLICIES: SCHOOL ABSENCES
Policy on School Absences for Dental

Appointments
Latest Reaffirmation How to Cite: American Academy of Pediatric Dentistry. Policy on
2019 school absences for dental appointments. The Reference Manual
Purpose school, and perform poorly in school compared with their

The American Academy of Pediatric Dentistry recognizes counterparts with better oral health status. 5 Children with
dental care is medically necessary and that poor oral health dental pain may be irritable, withdrawn, or unable to concen-
can negatively affect a child’s ability to learn. This policy is trate. Pain can affect test performance as well as school attend-
intended to assist public health and school education ance.1,6 Left untreated, the pain and infection caused by tooth
administrators in developing enlightened policies on school decay can lead to problems in eating, speaking, and learning.7
absence for dental appointments and support parents in The social impact of oral disease in children is substantial.
seeking medically necessary care for their children. More than 51 million school hours are lost each year to
dental related illness.1 On average, children and adolescents
Methods with oral health problems are absent one school day per
This policy was developed by the Council on Clinical Affairs year more than other children or adolescents.8 When these
and adopted in 2010. This document is a reaffirmation of the problems are treated and children no longer are experiencing
2015 version. An electronic database search was conducted pain, their learning and school attendance improve.2
using the terms: school absences for dental appointments, According to the U.S. Surgeon General, “a national public
excused school absences, and department of education. Papers health plan for oral health does not exist”.1 This corresponds
for review were chosen from this list and from references with the fact that there is no national policy on excused ab-
within selected articles. When data did not appear sufficient sences from school for dental appointments. Some states (e.g.,
or were inconclusive, statements were based on expert and/or California, Texas) have very specific laws excusing students for
consensus opinion by experienced researchers and clinicians. dental appointments.9,10 Other state laws are more general and
It is beyond the scope of this document to review every recognize absences due to doctor’s appointments or illness.11,12
state statute and regulation on absences from school for
dental appointments. Policy statement
Dental care is medically necessary, and oral health is integral
Background to general health. Undiagnosed and untreated oral conditions
Oral health is integral to general health. Many systemic dis- may interfere with a child’s ability to eat, sleep, or function
eases and conditions have oral manifestations. These oral well at home or at school due to discomfort or pain. The
manifestations may be the initial sign of clinical disease and unesthetic nature of caries and dental malocclusion may
indicate the need for further assessment.1 Oral conditions can compromise a child’s self-esteem and social development.
interfere with eating and adequate nutritional intake, speaking, Schools’ policies that prevent or discourage legitimate school
self-esteem, daily activities, and quality of life.2 Dental care is absence for the purpose of delivery of vital health care services
medically necessary to prevent and eliminate orofacial disease, may cause harm to their students.
infection, and pain. It is also important to restore the form Children who have their dental conditions corrected
and function of the dentition and correct facial disfiguration improve learning and attendance in school. State laws and
or dysfunction.3 The public’s lack of awareness of the im- local school district policies are not uniform on absences from
portance of oral health is a major barrier to dental care.1 Un- school for dental appointments. A uniform policy that
recognized disease and postponed care result in exacerbated recognizes the negative effect of chronic truancy on academic
problems, which lead to more extensive and costly treatment performance would be useful. Such policies should not restrict
needs.3 necessary health care delivery. The American Academy of
The National Association of State Boards of Education Pediatric Dentistry supports state law or school policy that
recognizes, “Health and success in schools are interrelated. allows the absence for legitimate health care delivery, in-
Schools cannot achieve their primary mission of education if cluding that of oral health services, and encourages parents,
students and staff are not healthy and fit physically, mentally, school administrators, and dentists to work together to ensure
and socially”.4 Children and adolescents with poorer oral that children receive dental care while minimizing school
health status are more likely to experience oral pain, miss absences.

ORAL HEALTH POLICIES: SCHOOL ABSENCES
References 6. Serawan H, Faust S, Muligan R. The impact of oral

1. U.S. Department of Health and Human Services. Oral health on academic performance of disadvantaged chil-
Health in America: A Report of the Surgeon General. dren. Am J Public Health 2012;102(9):1729-34.
Rockville, Md.: U.S. Department of Health and Human 7. U.S. General Accounting Office. Oral Health: Dental
Services, National Institute of Dental and Craniofacial Disease is a Chronic Problem Among Low-income and
Research, National Institutes of Health; 2000:12. Vulnerable Populations. Washington, D.C.: U.S. General
2. National Center for Education in Maternal and Child Accounting Office; 2000.
Health and Georgetown University. Fact sheet: Oral 8. Guarnizo-Herreno CC, Wehby GL. Children’s dental
health and learning. Arlington, Va.: NCEMCH; 2001. health, school performance, and psychosocial well-being.
Available at: “http://mchoralhealth.org/PDFs/learning J Pediatr 2012;161(6):1153-9.
factsheet.pdf ”. Accessed September 29, 2015. 9. California Education Code. Available at: “http://law.
3. American Academy of Pediatric Dentistry. Policy on onecle.com/california/education/48205.html”. Accessed
medically-necessary care. Pediatr Dent 2015;37(special September 29, 2015.
issue):18-22. 10. Texas Education Code. Available at: “http://law.onecle.
4. Bogden JF. General school health policies. Fit, Healthy, com/texas/education/25.087.html”. Accessed September
and Ready to Learn: A School Health Policy Guide. 29, 2015.
Alexandria, Va.: National Association of State Boards of 11. Georgia Department of Education. Available at: “https:
Education; 2000. Available at: “http://www.nasbe.org/ //www.gadoe.org/External-Affairs-and-Policy/State-
wp-content/uploads/C.-General-School-Health-Policies. Board-of-Education/SBOE%20Rules/160-5-1-.10.pdf ”.
pdf ”. Accessed September 29, 2015. Accessed September 29, 2015.
5. Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY. 12. Michigan Department of Education. Available at: “http:
Impact of poor oral health on children’s school attend- //www.Michigan.gov/documents/mde/compulsory_
ance and performance. Am J Public Health 2011;101(10): attendance_257944_7.pdf ”. Accessed September 29,
1900-6. 2015.

ORAL HEALTH POLICIES: EMERGENCY ORAL CARE
Policy on Emergency Oral Care for Infants, Children,

Adolescents, and Individuals with Special Health
Care Needs
2017 emergency oral care for infants, children, adolescents, and individuals
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2020:61.
The American Academy of Pediatric Dentistry recognizes This document was developed by the Policy and Review
emergency care for infants, children, adolescents, and indi- Committee and adopted in 1976. This document is an update
viduals with special health care needs is an essential duty of from the last revision in 2012.
every dentist. The American Dental Association’s Principles of
Ethics and Code of Professional Conduct states that “dentists References
shall be obliged to make reasonable arrangements for the 1. American Dental Association. Principles of Ethics and
emergency care of their patients of record”.1 The American Code of Professional Conduct. Available at: “http://
Academy of Pediatric Dentistry recommends dentists should www.ada.org/~/media/ADA/Publications/Files/ADA_
provide instructions to the parent for accessing emergency Code_of_Ethics_2016.pdf?la=en”. Accessed February
care.1 Availability of after-hours emergency care is an impor- ®
tant aspect of continually accessible care.2 Additionally, when citation.org/6tjJRjm6Q”)
consulted for a dental emergency by patients not of record, 2. Brecher EA, Keels MA, Quiñonez RB, Roberts MW,
the dentist should make reasonable arrangements for emergency Bordley WC. A policy review of after-hours emergency
dental care. If emergency dental treatment is provided, the dental care responsibilities. J Pub Health Dent 2016;76
dentist should recommend that the patient return to his/her (4):263-8.
dental home unless the parent expresses a different preference.1

ORAL HEALTH POLICIES: ROLE OF DENTAL PROPHYLAXIS
Policy on the Role of Dental Prophylaxis in

Pediatric Dentistry
2017 the role of dental prophylaxis in pediatric dentistry. The Reference
Purpose to remove calculus and stain. Full mouth debridement may be

The American Academy of Pediatric Dentistry presents this necessary as a preliminary treatment for those whose medical,
policy to assist practitioners in determining the indications psychological, physical, or periodontal condition result in
and methods for dental prophylaxis. calculus accumulation beyond the scope of routine prophyl-
axis. These procedures facilitate the clinical examination and
Methods introduce dental procedures to the patient. Additionally, the
This policy was developed by the Clinical Affairs Committee accompanying preventive visit demonstrates proper oral hy-
and adopted in 1986. This document is an update of the giene methods to the patient and/or caregiver. Flossing is an
previous version, revised in 2012. The revision included a important part of the prophylaxis that removes interproximal
new literature search of databases PubMed /MEDLINE and
Google Scholar using the terms: dental prophylaxis, tooth-
® and subgingival plaque, aidng in educating the patient and
facilitating the oral examination. The benefits of various
brushing, professional tooth cleaning, fluoride uptake, and prophylaxis options are shown in the Table below.
professional dental prophylaxis, limited to children, the last 10 Numerous reports have shown plaque and pellicle are not
years, and English language. Papers for review were chosen a barrier to fluoride uptake in enamel and, consequently, there
from relevant articles. Expert and/or consensus opinion by is no evidence of a difference in caries rates or fluoride uptake
experienced researchers and clinicians also was considered. in subjects who receive rubber cup coronal polish or a tooth-
brush coronal polish before fluoride treatment.3,4
Background A patient’s risk for caries/periodontal disease, as determined
The term dental prophylaxis encompasses several techniques by the patient’s dental provider, should help determine the
that are used by dental personnel to professionally remove interval of the prophylaxis or periodontal maintenance. An
plaque, stain, and calculus from patients’ teeth. Often, the individualized preventive plan increases the probability of good
toothbrush coronal polish (i.e., toothbrush and toothpaste) is oral health by demonstrating proper oral hygiene methods
a procedure that is used to remove plaque from tooth surfaces and techniques. In addition, removing plaque, stain, calculus,
and demonstrate brushing techniques to caregivers for young and the factors that influence their buildup increases the
children and for patients with special needs who cannot tol- probability of good oral health. Patients who exhibit higher
erate the use of a rubber cup.1 The rubber cup coronal polish risk for developing caries and/or periodontal disease should
is a procedure in which a dental polishing paste is applied to have recall visits at more frequent intervals.5,6
tooth surfaces with a rotary rubber cup or rotary bristle brush
to remove plaque and stains from teeth.2 Dental scaling is a Policy statement
procedure in which hand or ultrasonic instruments are used Professional prophylaxis is indicated to:
• Instruct the caregiver and child or adolescent in pro-
Table. BENEFITS OF PROPHYLAXIS OPTIONS per oral hygiene techniques.
• Remove dental plaque, extrinsic stain, and calculus
Plaque Stain Calculus Education of Facilitate
deposits from the teeth.
removal removal removal patient/parent examination
• Facilitate the examination of hard and soft tissues.
Toothbrush Yes No No Yes Yes • Introduce dental procedures to the young child and
Rubber cup Yes Yes No Yes Yes apprehensive patient.
Hand
Yes Yes Yes Yes Yes
instruments A patient’s risk for caries/periodontal disease helps deter-
Ultrasonic
Yes Yes Yes Yes Yes
mine the interval for recall. Those who exhibit higher risks
scalers should have recall visits more frequently than every six
Flossing Yes No No Yes Yes months.

ORAL HEALTH POLICIES: ROLE OF DENTAL PROPHYLAXIS
References 4. Weyant RJ, Tracy SL, Anselmo TT, et al. Topical fluoride
1. Ramos-Gomez F, Crystal YO, Ng MW, Tinanoff N, for caries prevention: Executive summary of the updat-
Featherstone JD. Caries risk assessment, prevention, and ed clinical recommendations and supporting systematic
management in pediatric dental care. Gen Dent 2010;58 review. J Am Dent Assoc 2013;144(11):1279-91.
(6):505-17; quiz 518-9. 5. Patel S, Bay RC, Glick M. A systematic review of dental
2. Wilkins EM. Extrinsic stain removal. Clinical Practice recall intervals and incidence of dental caries. J Am Dent
of Dental Hygenist. 10th ed. Baltimore, Md.: Lippincot Assoc 2010;141(5):527-39.
Williams and Wilkins; 2009:728-35. 6. American Academy of Pediatric Dentistry. Periodicity
3. Azarpazhooh A, Main PA. Efficacy of dental prophylaxis of examination, preventive dental services, anticipatory
(rubber cup) for the prevention of caries and gingivitis: guidance/counseling, and oral treatment for infants,
A systematic review of literature. Br Dent J 2009;207 children, and adolescents. Pediatr Dent 2017;39(6):
(7):E14; discussion 328-9. 188-96.

ORAL HEALTH POLICIES: USE OF FLUORIDE
Policy on Use of Fluoride

2018 use of fluoride. The Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2020:64-5.
Purpose infant formulas in the U.S. is 0.15 ppm for milk-based formulas
The American Academy of Pediatric Dentistry (AAPD) affirms and 0.21 ppm for soy-based formulas.11 The more important
that the use of fluoride as an adjunct in the prevention of issue, however, is the fluoride content of concentrated or
caries is safe and effective. The AAPD encourages dentist and powdered formula when reconstituted with fluoridated water.
other health care providers, public health officials, and parents/ The range of fluoride in ppm for reconstituted powdered or
caregivers to optimize fluoride exposures to reduce the risk for liquid concentrate, when reconstituted with water containing
caries and to enhance the remineralization of affected tooth 1 ppm fluoride, is 0.64 -1.07.11 As the Environmental Protec-
structures. tion Agency/Department of Health and Human Services’
recommendation12 for optimizing community water supplies to
Methods 0.7 ppm fluoride is instituted, fluorosis due to reconstituting
This document was developed by the Liaison with Other infant formula with fluoridated water is less of an issue.
Groups Committee and adopted in 1967. This is an update Significant cariostatic benefits can be achieved by the use
from the last revision in 2014. An electronic database search of over-the-counter fluoride-containing preparations such as
using the terms: fluoride, fluoridation, acidulated phosphate toothpastes, gels, and rinses, especially in areas without water
fluoride, fluoride varnish, fluoride therapy, and topical fluoride fluoridation.2 The brushing of teeth with appropriate amounts
previously was conducted to develop and update this policy. of fluoride toothpaste twice daily for all children is encour-
The current update relied upon systematic reviews, expert opi- aged.13 Monitoring children’s use of topical fluoride-containing
nions, and best current practices. The use of silver diamine products, including toothpaste, may prevent ingestion of
fluoride is addressed in a separate AAPD policy.1 excessive amounts of fluoride.13,14 Numerous clinical trials
have confirmed the anti-caries effect of professional topical
Background fluoride treatments, including 1.23 percent acidulated phos-
The adjustment of the fluoride level in community water phate fluoride [(APF); 1.23 percent fluoride], five percent
supplies to optimal concentration is the most beneficial and sodium fluoride varnish [(NaFV); 2.26 percent fluoride], 0.09
inexpensive method of reducing the occurrence of caries.2 percent fluoride mouthrinse, and 0.5 percent fluoride gel/
Long-term use of fluorides has reduced the cost of oral health paste.15 For children under the age of six years, five percent
care for children by as much as 50 percent.3 When public sodium fluoride varnish in unit doses,which reduce the
water is fluoridated to an optimal level, there is a 35 percent potential for harm, is the recommended professionally-applied
reduction in decayed, missing, and filled primary teeth and 26 topical fluoride agent.15
percent fewer decayed, missing, and filled permanent teeth.4 A significant number of parents and caregivers are con-
The occurrence of fluorosis, causing esthetic concerns, has cerned about their child receiving fluoride and may refuse
been reported to be 12 percent when public water contains fluoride treatment even though fluoride is safe and effective.16
0.7 parts per million (ppm) fluoride.4 When combined with This is similar to opposition to community water fluorida-
other dietary, oral hygiene, and preventive measures5, the use tion.17 Topical fluoride refusal and resistance may be a growing
of fluorides can further reduce the incidence of caries. problem and mirror trends seen with vaccination refusal in
Professional fluoride products should only be applied by medicine.
or under the direction of a dentist or physician who is fa-
miliar with the child’s oral health and has completed a caries Policy statement
risk assessment. When fluoridation of drinking water is im- The AAPD:
possible, effective fluoride supplementation can be achieved • Endorses and encourages the adjustment of fluoride
through the intake of daily fluoride supplements according to content of public drinking water supplies to optimal
established guidelines.2,6-8 Before supplements are prescribed, levels where feasible.
it is essential to review dietary sources of fluoride (e.g., all
drinking water sources, consumed beverages, prepared food,
toothpaste) to determine the patient’s true exposure to ABBREVIATIONS
fluoride,2,9,10 and to take into consideration the caries risk of AAPD: American Academy Pediatric Dentistry. ppm: parts per million.
the child. The mean fluoride concentration of ready-to-feed

ORAL HEALTH POLICIES: USE OF FLUORIDE
• Endorses the supplementation of a child’s diet with 6. Rozier RG, Adair S, Graham F, et al. Evidence-based
fluoride according to established guidelines when clinical recommendations on the prescription of dietary
fluoride levels in public drinking water are suboptimal fluoride supplements for caries prevention: A report of
and after consideration of sources of dietary fluoride the American Dental Association Council on Scientific
and the caries risk of the child. Affairs. J Am Dent Assoc 2010;141(12):1480-9.
• Encourages the brushing of teeth with appropriate 7. Clark MB, Slayton RL, American Academy of Pediatrics
amounts of fluoride toothpaste twice daily for all Section on Oral Health. Clinical report: Fluoride use in
children.11 caries prevention in the primary care setting. Pediatrics
• Encourages the application of professional fluoride 2014;134(3):626-33.
treatments for all individuals at risk for dental caries. 8. American Academy of Pediatric Dentistry. Fluoride
• Encourages dental professionals to inform medical therapy. Pediatr Dent 2018;40(6):250-3.
peers of the potential of enamel fluorosis when excess 9. Levy SM, Kohout FJ, Kiritsy MC, Heilman JR, Wefel JS.
fluoride is ingested prior to enamel maturation. Infants’ fluoride ingestion from water, supplements, and
• Encourages the continued research on safe and dentifrice. J Am Dent Assoc 1995;126(12):1625-32.
effective fluoride products. 10. Adair SM. Evidence-based use of fluoride in contem-
• Supports the delegation of fluoride application to porary pediatric dental practice. Pediatr Dent 2006;28
auxiliary dental personnel or other trained allied health (2):133-42.
professionals by prescription or order of a dentist after 11. Berg J, Gerweck C, Hujoel PP, et al. Evidence-based
a comprehensive oral examination or by a physician clinical recommendations regarding fluoride intake from
after a dental screening has been performed. reconstituted infant formula and enamel fluorosis. J Am
• Encourages all beverage and infant formula manu- Dent Assoc 2011;142(1):79-87.
facturers to include fluoride concentration with the 12. U.S. Department of Health and Human Services Federal
nutritional content on food labels. Panel on Community Water Fluoridation. U.S. Public
• Recognizes that drinking fluoridated water and brush- Health Service recommendation for fluoride concentra-
ing with fluoridated toothpaste twice daily are the most tion in drinking water for the prevention of dental caries.
effective method in reducing dental caries prevalence Public Health Reports 2015;130(4):1-14.
in children. 13. American Dental Association Council on Scientific
• Encourages dental providers to talk to parents and Affairs. Fluoride toothpaste use for young children. J Am
caregivers about the benefits of fluoride and to pro- Dent Assoc 2014;145(2):190-1.
actively address fluoride hesitance through chairside 14. Warren JJ, Levy SM. A review of fluoride dentifrice
and community education. related to dental fluorosis. Pediatr Dent 1999;21(4):
265-71.
References 15. Weyant RJ, Tracy SL, Anselmo T, Beltrán-Aguilar
1. American Academy of Pediatric Dentistry. Policy on use EJ, Donly KJ, Frese WA. Topical fluoride for caries
of silver diamine fluoride for pediatric dental patients. prevention: Executive summary of the updated clinical
Pediatr Dent 2018;40(6):51-4. recommendations and supporting systematic review. J
2. Centers for Disease Control and Prevention. Recom- Am Dent Assoc 2013;144(11):1279-91. Erratum in J Am
mendations for using fluoride to prevent and control Dent Assoc 2013;144(12):1335. Dosage error in article
dental caries in the United States. MMWR Recomm text.
Rep 2001;50(RR14):1-42. 16. Chi DL. Caregivers who refuse preventive care for their
3. Griffen SO, Jones K, Tomar, SL. An economic evaluation children: The relationship between immunization and
of community water fluoridation. J Pub Health Dent topical fluoride refusal. Am J Public Health 2014;104
2001;61(2):78-86. (7):1327-33.
4. Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water 17. Melbye ML, Armfield JM. The dentist’s role in pro-
fluoridation for the prevention of dental caries. Cochrane moting community water fluoridation: A call to action
Database Syst Rev 2015;(6):CD010856. for dentists and educators. J Am Dental Assoc 2013;
5. Featherstone JD. The science and practice of caries 144(1):65-75.
prevention. J Am Dent Assoc 2000;131(7):887-99.

ORAL HEALTH POLICIES: USE OF SILVER DIAMINE FLUORIDE
Policy on the Use of Silver Diamine Fluoride for

Pediatric Dental Patients
2018 the use of silver diamine fluoride for pediatric dental patients.
Purpose and there are current policies and guidelines with recom-
The American Academy of Pediatric Dentistry (AAPD) mendations for their use in the practice of dentistry. 1-3 In
recognizes that dental caries continues to be a prevalent and contrast, treatment of caries lesions traditionally requires
severe disease in children. This policy addresses the use of surgical intervention to remove diseased tooth structure
silver diamine fluoride (SDF) as part of an ongoing caries followed by placement of a restorative material to restore
management plan with the aim of optimizing individualized form and function. Barriers to traditional restorative treatment
patient care consistent with the goals of a dental home. When (e.g., behavioral issues due to age and/or limited cooperation,
SDF is indicated, it is essential that the infants, children, access to care, financial constraints) call for other alternative
adolescents, or individuals with special health care needs caries management modalities.
receive a comprehensive dental examination, diagnosis, and Silver topical products, such as silver nitrate and SDF have
plan of ongoing disease management prior to placement of been used in Japan for over 40 years to arrest caries and reduce
the material. The dental profession has long viewed dental tooth hypersensitivity in primary and permanent teeth. Dur-
caries as an acute disease condition requiring surgical ing the past decade, many other countries such as Australia
debridement, cavity preparation, and mechanical restoration and China have been using this compound with similar suc-
of the tooth, but increasingly, especially for the infant and cess.4,5 As marketed in the United States, SDF is a 38 percent
child population, practitioners are utilizing individually silver diamine fluoride which is equivalent to five percent
tailored strategies to prevent, arrest, or ameliorate the disease fluoride in a colorless liquid, with a pH of 10. The exact
process based on caries risk assessment. One of these strategies mechanism of SDF is not understood. It is theorized that
employs application of SDF as an antimicrobial and reminer- fluoride ions act mainly on the tooth structure, while silver
alization agent to arrest caries lesions after diagnosis and at ions, like other heavy metals, are antimicrobial. It also is
the direction of a responsible dentist of record. theorized that SDF reacts with hydroxyapatite in an alkaline
environment to form calcium fluoride (CaF2) and silver phos-
Methods phate as major reaction products. CaF2 provides sufficient
This document was developed by the Council on Clinical fluoride to form fluorapatite which is less soluble than
Affairs and adopted in 2017. This policy is a review of current hydroxy-apatite in an acidic environment.6,7 A side effect is the
dental and medical literature and sources of recognized pro- discoloration of demineralized or cavitated surfaces. Patients
fessional expertise and stature, including both the academic and parents should be advised regarding the black staining of
and practicing health communities, related to SDF and the lesions associated with the application of SDF. Ideally,
silver nitrate. In addition, literature searches of PubMed / ® prior to use of SDF, parents should be shown before-and-
MEDLINE and Google Scholar databases were conducted after images of teeth treated with SDF. Recently, the U.S.
using the terms: diamine silver fluoride and caries, Howe’s Food and Drug Administration approved SDF as a device for
solution, silver nitrate and caries, and silver diamine fluoride; reducing tooth sensitivity, and off-label use for arresting caries
fields: all; limits: within the last 15 years, humans, English, is now permissible and appropriate for patients.8-12
birth through age 99. One hundred eight articles matched Many clinical trials have evaluated the efficacy of SDF on
these criteria. Papers for review were chosen from this list caries arrest and/or prevention,6,10-33 although clinical trials
and from the references within selected articles. Expert and/ have inherent bias because of the staining (i.e., since the
or consensus opinion by experienced researchers and clini- difference between control and treated teeth is obvious to the
cians also was considered. researcher). However, studies consistently conclude that SDF
Background
Treatment of incipient caries usually involves early therapeutic ABBREVIATIONS
intervention using topical fluoride, and non-surgical restorative AAPD: American Academy of Pediatric Dentistry. CaF2: Calcium
techniques such as dental sealants and resin infiltration. The use fluoride. SDF: Silver diamine fluoride.
and outcomes of these techniques have been well-documented,

is indeed more effective for arresting caries 6,10-12,17-33 than • Supports third-party reimbursement for fees associated
fluoride varnish. SDF reportedly also has approximately 2-3 with SDF.
times more fluoride retained than delivered by sodium • Supports delegation of application of SDF to auxiliary
fluoride, stannous fluoride, or acidulated phosphate fluoride dental personnel or other trained health professionals
(APF) commonly found in foams, gels, and varnishes.28 Addi- according to a state’s dental practice act by prescrip-
tionally, SDF has not been shown to reduce adhesion of resin tion or order of a dentist after a comprehensive oral
or glass ionomer restorative materials.6,3-37 The use of SDF is examination.
safe when used in adults and children.38-41 Placement of SDF • Supports a consultation with the patient/parent with
should follow the AAPD’s Chairside Guide: Silver Diamine an informed consent recognizing SDF is a valuable
Fluoride in the Management of Dental Caries Lesions.41 Dele- therapy which may be included as part of a caries
gation of the application of SDF to auxiliary dental personal management plan.
or other trained health professionals, as permitted by state • Supports the education of dental students, residents,
law, must be by prescription or order of the dentist after a other oral health professionals and their staffs to
comprehensive oral examination. ensure a good understanding of appropriate coding
The ultimate decision regarding disease management and and billing practices.
application of SDF are to be made by the dentist and the • Encourages more practice-based research to be
patient/parent, acknowledging individuals’ differences in conducted on SDF to evaluate its efficacy.
disease propensity, lifestyle, and environment.42 Dentists are
“required to provide information about the dental health References
problems observed, the nature of any proposed treatment, the 1. American Academy of Pediatric Dentistry. Fluoride
potential benefits and risks associated with the treatment, any therapy. Pediatr Dent 2018;40(6):250-3.
alternatives to the treatment proposed, and potential risks and 2. American Academy of Pediatric Dentistry. Pediatric
benefits of alternative treatment, including no treatment.” 43 restorative dentistry. Pediatr Dent 2018;40(6):330-42.
The SDF informed consent, particularly highlighting expected 3. American Academy of Pediatric Dentistry. Policy on use
staining of treated lesions, potential staining of skin and of fluoride. Pediatr Dent 2018;40(6):49-50.
clothes, and the need for reapplication for disease control, is 4. Mei ML, Zhao IS, Ito L, et al. Prevention of secondary
recommended. 41 Careful monitoring and behavioral inter- caries by silver diamine fluoride. Int Dent J 2016;66
vention to reduce individual risk factors should be part of a (2):71-7.
comprehensive caries management program that aims not 5. Zhao IS, Gao SS, Hiraishi N, et al. Mechanisms of silver
only to sustain arrest of existing caries lesions, but also to diamine fluoride on arresting caries: A literature review.
prevent new caries lesion development.42 Although no severe Int Dent J 2018;68(2):67-76.
pulpal damage or reaction to SDF has been reported, SDF 6. Fung MHT, Wong MCM, Lo ECM, Chu CH. Arrest-
should not be placed on exposed pulps. 42 Therefore, teeth ing early childhood caries with silver diamine fluoride–
with deep caries lesions should be closely monitored clinically A literature review. J Oral Hyg Health 2013;1:117.
and radiographically by a dentist.42 Available at: “https://www.omicsonline.org/open-access/
SDF, when used as a caries arresting agent, is a reimburs- arresting-early-childhood-caries-with-silver-diamine-
able fee through billing to a third-party payor, when submitted fluoridea-literature-review-2332-0702.1000117.php?aid
with the appropriate dental code recognized by the American =21896”. Accessed September 25, 2017. (Archived by
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®
ment for this procedure varies among states and carriers. 7. Yamaga R, Nishino M, Yoshida S, Yokomizo I. Diammine
Third-party payors’ coverage is not consistent on the use of the silver fluoride and its clinical application. J Osaka Univ
code per tooth or per visit.42 Because there is a recommended Dent Sch 1972;12:1-20.
code for SDF application, billing the procedure using any 8. Mei ML, Lo EC, Chu CH. Clinical use of silver diamine
other code would constitute fraud, as defined by the Federal fluoride in dental treatment. Compend Contin Educ
Code of Regulations.45 The AAPD supports the education of Dent 2016;37(2):93-8; quiz100.
dental students, residents, other oral health professionals and 9. Sharma G, Puranik MP, K RS. Approaches to arresting
their staffs to ensure good understanding of the appropriate dental caries: An update. J Clin Diagn Res 2015;9(5):
coding and billing practices to avoid fraud.46 ZE08-11.
10. Gao SS, Zhang S, Mei ML, Lo EC, Chu CH. Caries
Policy statement remineralisation and arresting effect in children by
The AAPD: professionally applied fluoride treatment – A systematic
• Supports the use of SDF as part of an ongoing caries review. BMC Oral Health 2016;16:12.
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Dent 2016;51:15-20. 27. Beltrán-Aguilar ED. Silver diamine fluoride (SDF) may
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guide: Silver diamine fluoride in the management of 45. U.S. National Archives and Records Administration.
dental caries lesions. Pediatr Dent 2018;40(6):492-3. 2018. Code of Federal Regulations. Title 42-Public
42. Crystal YO, Marghalani AA, Ureles SD, et al. Use of Health. Part 455-Program Integrity: Medicaid. Section
silver diamine fluoride for dental caries management in 455.2-Definitions. Available at: “https://wwwecfr.gov/
children and adolescents, including those with special cgi-bin/text-idx?tpl=/ecfrbrowse/Title42/42cfr455_main
health care needs. Pediatr Dent 2017;39(5):E135-E145.
43. American Dental Association Division of Legal Affairs.
_02.tpl”. Accessed May 2, 2018. (Archived by WebCite
at: “http://www.webcitation.org/6z7WVaF9d”)
®
Dental Records. Chicago, Ill.: American Dental Associ- 46. American Academy of Pediatric Dentisty. Policy on
ation; 2007:16. third-party payor audits, abuse, and fraud. Pediatr Dent
2018;40(6):126-9.

ORAL HEALTH POLICIES: USE OF XYLITOL
Policy on Use of Xylitol in Pediatric Dentistry

2020 use of xylitol in pediatric dentistry. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
Purpose children, and MS levels in children.5-11,13-16 Such studies have

The American Academy of Pediatric Dentistry (AAPD) been performed with xylitol intake ranging from four to 15
recognizes that there is considerable research on sugar sub- grams per day divided into three to seven consumption
stitutes, particularly xylitol, and their potential oral health periods.7-9 Abdominal distress and osmotic diarrhea have been
benefits for infants, children, adolescents, and persons with reported following the ingestion of xylitol.7-13,15-18
special health care needs. This policy is intended to assist oral Overall results of systematic reviews suggest insufficient
health care professionals making informed decisions about the evidence to show xylitol products reduce caries. 7-13,15-18 All
use of xylitol-based products with the aim of preventing caries xylitol studies were reported to have design issues and/or
in children. bias (e.g., insufficient sample size, control group issues, in-
consistent results, randomization, blinding, conflict of inter-
Methods est). 7-13,15-18 Data is inconclusive for caries reduction for
This policy was developed by the Council on Clinical Affairs short-term use.7-13,15-18 Data also is inconclusive for long-term
and adopted in 2006.1 This document is an update of the effectiveness for reduction of MS and caries reduction.7-13,15-18
previous version, revised in 2015.2 The update is based upon Most studies used a very large dose and at high frequency
a review of current dental and medical literature related to (generally four to five times a day), which may be unrealistic
the use of xylitol in caries prevention. A literature search was in clinical practice.10-12
®
conducted using PubMed /Ovid with the terms: xylitol
AND dental, systematic review; field: all fields; limits: Policy statement
within the last 10 years, humans, English, birth through 18. The AAPD:
Twenty-three articles matched these criteria; 16 systematic • Supports the use of xylitol and other sugar alcohols as
reviews and/or meta-analyses were reviewed for this revision. non-cariogenic sugar substitutes.
When data did not appear sufficient or were inconclusive, • Recognizes that presently there is a lack of consistent
policy was based upon expert and/or consensus opinion by evidence showing significant reductions in MS and
experienced researchers and clinicians. dental caries in children.
• Recognizes that the large dose and at high frequency
Background of xylitol used in clinical trials may be unrealistic in
Xylitol is a five-carbon sugar alcohol derived primarily from clinical practice.
forest and agricultural materials.3 It has been used since the • Supports further research to clarify the impact of xyli-
early 1960s in infusion therapy for post-operative, burn, and tol delivery vehicles, the frequency of exposure, and the
shock patients, in the diet of diabetic patients, and as a sweet- optimal dosage to reduce caries and improve the oral
ener in products aimed at improved oral health.3 Dental health of children.
benefits of xylitol first were suggested from Finnish studies
using animal models in 1970.4 The first xylitol studies in References
humans, known as the Turku Sugar Studies,5,6 demonstrated 1. American Academy of Pediatric Dentistry. Use of xylitol
the relationship between dental plaque and xylitol, as well as in caries prevention. Pediatr Dent 2006;28(suppl):31-2.
the safety of xylitol for human consumption. Xylitol as well as 2. American Academy of Pediatric Dentistry. Use of xylitol.
other sugar alcohols are not readily metabolized by oral bacte- Pediatr Dent 2015;37(special issue):45-7.
ria and, thus, are considered non-cariogenic sugar substitutes.6 3. Mäkinen KK. Biochemical principles of the use of xylitol
Xylitol is available in many forms (e.g., gums, mints, in medicine and nutrition with special consideration
chewable tablets, lozenges, toothpastes, mouthwashes, cough of dental aspects. Experientia Suppl 1978;30:1-160.
mixtures, oral wipes, nutraceutical products).7 The chewing
process enhances the caries inhibitory effect, which may be
a significant confounding factor for the efficacy of xylitol ABBREVIATIONS
gum.7-14 Multiple systematic reviews regarding xylitol show AAPD: American Academy Pediatric Dentistry. MS: mutans
varying results in the reduction of the incidence of caries, streptococci.
transmission of mutans streptococci (MS) from mothers to

ORAL HEALTH POLICIES: USE OF XYLITOL
4. Muhlemann HR, Regolati B, Marthaler TM. The effect 11. Janakiram C, Deepan Kumar CV, Joseph J. Xylitol in
on rat fissure caries of xylitol and sorbitol. Helv Odontol preventing dental caries: A systematic review and meta-
Acta 1970;14(1):48-50. analyses. J Nat Sci Biol Med 2017;8(1):16-21.
5. Scheinin A, Mäkinen KK, Tammisalo E, Rekola M. Turku 12. Marghalani AA, Guinto E, Phan M, Dhar V, Tinanoff N.
sugar studies. XVIII. Incidence of dental caries in rela- Effectiveness of xylitol in reducing dental caries in chil-
tion to 1-year consumption of xylitol chewing gum. Acta dren. Pediatr Dent 2017;39(2):103-10.
Odontol Scand 1975;33(5):269-78. 13. Mickenautsch S, Yengopal V. Anticariogenic effect of
6. Scheinin A, Mäkinen KK, Ylitalo K. Turku sugar stud- xylitol versus fluoride – A quantitative systematic review
ies. V. Final report on the effect of sucrose, fructose and of clinical trials. Int Dent J 2012;62(1):6-20.
xylitol diets on caries incidence in man. Acta Odontol 14. Nakai Y, Shinga-Ishihara C, Kaji M, Moriya K, Murakami-
Scand 1976;34(4):179-216. Yamanaka K, Takimura M. Xylitol gum and maternal
7. Riley P, Moore D, Ahmed F, Sharif MO, Worthington transmission of mutans streptococci. J Dent Res 2010;
H. Xylitol-containing products for preventing dental 89(1):56-60.
caries in children and adults. Cochrane Database Syst 15. Fontana M. Enhancing fluoride: Clinical human studies
Rev 2015;(3):CD010743. of alternatives or boosters for caries management. Caries
8. Antonio AG, Pierro VS, Maia LC. Caries preventive Res 2016;50(Suppl 1):22-37.
effects of xylitol-based candies and lozenges: A systematic 16. Muthu MS, Ankita S, Renugalakshmi A, Richard K. Im-
review. J Public Health Dent 2011;71(2):117-24. pact of pharmacological interventions in expectant
9. Lin HK, Fang CE, Huang MS, et al. Effect of maternal mothers resulting in altered mutans streptococci levels
use of chewing gums containing xylitol on transmission in their children. Pediatr Dent 2015;37(5):422-8.
of mutans streptococci in children: A meta-analysis of 17. Wang Y, Li J, Sun W, Li H, Cannon R, Mei L. Effect of
randomized controlled trials. Int J Paediatr Dent 2016;26 non-fluoride agents on the prevention of dental caries in
(1):35-44. primary dentition: A systematic review. PLoS One 2017;
10. Chou R, Cantor A, Zakher B, et al. Prevention of Dental 12(8):e0182221.
Caries in Children Younger Than 5 Years Old: Systematic 18. Xiao J, Alkhers N, Kopycka-Kedzierawskial DT, et al.
Review to Update the U.S. Preventive Services Task Force Prenatal oral health care and early childhood caries pre-
Recommendation [Internet]. Rockville, Md.: Agency for vention: A systematic review and meta-analysis. Caries
Healthcare Research and Quality; May 2014. (Evidence Res 2019;53(4):411-21.
Syntheses, No. 104.) Available at: “https://www.ncbi.nlm.
nih.gov/books/NBK202090/”. Accessed July 22, 2020.

ORAL HEALTH POLICIES: INTERIM THERAPEUTIC RESTORATIONS
Policy on Interim Therapeutic Restorations ( ITR )

2017 interim therapeutic restorations (ITR). The Reference Manual of
Purpose Additionally, ITR may be used for step-wise excavation in

The American Academy of Pediatric Dentistry (AAPD) children with multiple open carious lesions prior to definitive
recognizes that unique clinical circumstances can result in restoration of the teeth, in erupting molars when isolation
challenges in restorative care for infants, children, adolescents, conditions are not optimal for a definitive restoration, or for
and persons with special health care needs. When circum- caries control in patients with active lesions prior to treatment
stances do not permit traditional cavity preparation and/or performed under general anesthesia.9,10 The use of ITR has
placement of traditional dental restorations or when caries been shown to reduce the levels of cariogenic oral bacteria
control is necessary prior to placement of definitive restora- (e.g., Mutans streptococci, lactobacilli) in the oral cavity im-
tions, interim therapeutic restorations (ITR)1 may be beneficial mediately following its placement.11-13 However, this level may
and are best utilized as part of comprehensive care in the return to pretreatment counts over a period of six months
dental home.2,3 This policy will differentiate ITR from after ITR placement if no other treatment is provided.12
atraumatic/alternative restorative techniques (ART)4 and The ITR procedure involves removal of caries using hand
describe the circumstances for its use. or rotary instruments with caution not to expose the pulp.
Leakage of the restoration can be minimized with maximum
Methods caries removal from the periphery of the lesion. Following
This policy was developed by the Council on Clinical Affairs preparation, the tooth is restored with an adhesive restorative
and adopted in 2001. This document is a revision of the material such as glass ionomer or resin-modified glass ionomer
previous version, revised in 2013. This updated policy is based cement.14 ITR has the greatest success when applied to single
upon electronic database and hand searches of medical and surface or small two surface restorations.15,16 Inadequate cavity
dental literature using the terms: dental caries, cavity, pri- preparation with subsequent lack of retention and insufficient
mary teeth, deciduous teeth, atraumatic restorative treatment, bulk can lead to failure.16,17 Follow-up care with topical fluor-
interim therapeutic restoration, AND glass ionomer; fields: ides and oral hygiene instruction may improve the treatment
all; limits: within the last 10 years, humans, English, birth outcome in high caries-risk dental populations, especially
through age 18. Additionally, websites for the AAPD and the when glass ionomers (which have fluoride releasing and re-
American Dental Association were reviewed. Expert and/or charging properties) are used.18-20
consensus opinion by experienced researchers and clinicians
was also considered. Policy statement
The AAPD recognizes ITR as a beneficial provisional technique
Background in contemporary pediatric restorative dentistry. ITR may be
ART has been endorsed by the World Health Organization as used to restore and prevent the progression of dental caries
a means of restoring and preventing caries in populations with in young patients, uncooperative patients, patients with spe-
little access to traditional dental care.4-6 In many countries, cial health care needs, and situations in which traditional
practitioners provide treatment in non-traditional settings that cavity preparation and/or placement of traditional dental
restrict restorative care to placement of provisional restora- restorations are not feasible. ITR may be used for caries
tions. Because circumstances do not allow for follow-up care, control in children with multiple carious lesions prior to
ART mistakenly has been interpreted as a definitive restoration. definitive restoration of the teeth.
ITR utilizes similar techniques but has different therapeutic
goals. Interim therapeutic restoration more accurately describes
the procedure used in contemporary dental practice in the
United States.
ITR may be used to restore, arrest or prevent the pro- ABBREVIATIONS
gression of carious lesions in young patients, uncooperative AAPD: American Academy Pediatric Dentistry. ART: Atraumatic/
patients, or patients with special health care needs or when alternative restorative techniques. ITR: Interim therapeutic
traditional cavity preparation and/or placement of traditional restorations.
dental restorations are not feasible and need to be postponed.7,8

ORAL HEALTH POLICIES: INTERIM THERAPEUTIC RESTORATIONS
References 11. Bönecker M, Toi C, Cleaton-Jones P. Mutans strepto-

1. American Academy of Pediatric Dentistry. Pediatric cocci and lactobacilli in carious dentine before and after
restorative dentistry. Pediatr Dent 2017;39(6):312-24. Atraumatic Restorative Treatment. J Dent 2003;31(6):
2. Nowak AJ, Casamassimo PS. The dental home. J Am 423-8.
Dent Assoc 2002;133(1):93-8. 12. Roshan NM, Shigli AL, Deshpande SD. Microbiological
3. American Academy of Pediatric Dentistry. Policy on the evaluation of salivary Streptococcus mutans from children
dental home. Pediatr Dent 2017;39(6):29-30. of age 5-7 years, pre- and post-atraumatic restorative
4. Frencken J, Pilot T, van Amerongen E, Phantumvanit P, treatment. Contemp Clin Dent 2010;1(2):94-7.
Songpaisan Y. Manual for the atraumatic restorative 13. Wambier DS, dosSantos FA, Guedes-Pinto AC, Jaeger
treatment approach to control dental caries. WHO Col- RG, Simionato MRL. Ultrastructural and microbiological
laboration. Centre for Oral Health Services Research. analysis of the dentin layers affected by caries lesions in
Groningen, The Netherlands; 1997. Available at: “https:// primary molars treated by minimal intervention. Pediatr
www.researchgate.net/profile/Yupin_Songpaisan/publica Dent 2007;29(3):228-34.
tion/228553340_Manual_for_the_Atraumatic_Restaurative 14. Yip HK, Smales RJ, Ngo HC, Tay FR, Chu F. Selection
_Treatment_approach_to_control_dental_caries/links/ of restorative materials for the atraumatic restorative
02e7e51f0ef4f102d1000000.pdf ”. Accessed November treatment (ART) approach: A review. Spec Care Dent
®
6, 2016. (Archived by WebCite at: “http://www.web 2001;21(6):216-221.
citation.org/6owJnTvED”) 15. Mandari GJ, Frencken JE, van’t Hof MA. Six-year success
5. World Health Organization. Atraumatic Restorative rates of occlusal amalgam and glass-ionomer restorations
Treatment. Available at: “http://new.paho.org/hq/index. placed using three minimal intervention approaches.
php?option=com_content&view=article&id=7411&Itemid Caries Res 2003;37(4):246-53.
=39633&lang=en”. Accessed November 6, 2016. 16. da Franca C, Colares V, Van Amerongen E. Two-year
®
(Archived by WebCite at: “http://www.webcitation.org/ evaluation of the atraumatic restorative treatment ap-
6owJ9ZsBN”) proach in primary molars class I and II restorations. Int
6. Frencken JE. The ART approach using glass-ionomers in J Paediatr Dent 2011;21(4):249-53.
relation to global oral health care. Dent Mater 2010;26 17. van Gemert-Schriks MCM, van Amerongen WE, ten
(1):1-6. Cate JM, Aartman IHA. Three-year survival of single-
7. Deery C. Atraumatic restorative techniques could reduce and two-surface ART restorations in a high-caries child
discomfort in children receiving dental treatment. Evid population. Clin Oral Investig 2007;11(4):337-43.
Based Dent 2005;6:9. 18. Tam LE, Chan GP, Yim D. In vitro caries inhibition
8. Gryst ME, Mount GJ. The use of glass ionomer in effects by conventional and resin modified glass ionomer
special needs patients. Aust Dent J 1999;44(4):268-74. restorations. Oper Dent 1997;22(1):4-14.
9. Vij R, Coll JA, Shelton P, Farooq NS. Caries control and 19. Scherer W, Lippman N, Kaim J, LoPresti J. Antimicrobial
other variables associated with success of primary molar properties of VLC liners. J Esthet Dent 1990;2(2):31-2.
vital pulp therapy. Pediatr Dent 2004;26(3):214-20. 20. Tyas MJ. Cariostatic effect of glass ionomer cements: A
10. Antonson SA, Antonson DE, Brener S, et al. Twenty-four five-year clinical study. Aust Dent J 1991;36(3):236-9.
month clinical evaluation of fissure sealants on partially
erupted permanent first molars: Glass ionomer versus
resin-based sealant. J Am Dent Assoc 2012;143(2):115-22.

ORAL HEALTH POLICIES: MANAGEMENT OF THE FRENULUM
Policy on Management of the Frenulum in

Pediatric Dental Patients
Adopted How to Cite: American Academy of Pediatric Dentistry. Policy on
2019 management of the frenulum in pediatric dental patients. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Purpose Background
Evidence suggests that the frequency of frenotomy/frenectomy Frenulum attachments and their impact on oral motor func-
is increasing, with reports indicating as much as a 90 percent tion and development have become topics of emerging interest
increase in recent years.1,2 The American Academy of Pediatric within the dental community as well as various specialties of
Dentistry recognizes a policy on frenula would make infor- healthcare providers. Studies have shown differences in treat-
mation and recommendations more accessible to dentists, ment recommendations among pediatricians, otolaryngologists,
physicians, and other allied health professionals in an evidence- lactation consultants, speech pathologists, surgeons, and dental
based format. specialists.3-10 Clear indications and timing of surgical treatment
remain controversial due to lack of consensus regarding
Methods accepted anatomical and diagnostic criteria for degree of
This policy, developed by the Council of Clinical Affairs, is restriction and relative impact on growth, development,
a review of current dental and medical literature and sources feeding, or oral motor function.3-10 Although the etiology of
of recognized professional expertise and stature, including this condition remains unknown, there appears to be a higher
both the academic and practicing health communities, related predilection of anomalies of frenulum attachments, whether
to frenula/frenotomies. In addition, literature searches of ankyloglossia (tongue-tie) or a hypertrophic/restrictive maxil-
®
PubMed /MEDLINE and Google Scholar databases were
conducted using the terms: ankyloglossia, ankyloglossia
lary labial frenulum, in males.9-13 Typically, seven frenula are
present in the oral cavity, most notable the maxillary labial
AND breastfeeding outcomes, breastfeeding with ankylo- frenulum, the mandibular labial frenulum, the lingual frenulum,
glossia and/or upper lip tie, gastroesophageal reflux, frenotomy, and four buccal (cheek) frenula.14 Their primary function is
frenulotomy, systematic reviews of ankyloglossia other than to provide stability of the upper lip, lower lip, and tongue.15
breastfeeding, lip-tie, super labial frenulum, maxillary lip-tie,
breastfeeding cessation, frenulum, frenum, tongue-tie, speech Maxillary frenulum
articulation with lingual frenulum, frenuoplasty, midline dia- A prominent maxillary frenulum in infants, children, and
stema, lactation difficulties, nipple pain with breastfeeding, adolescents, although a common finding, is often a concern
Hazelbaker Assessment Tool for Lingual Frenulum Function to parents. The maxillary labial frenulum attachment can be
(ATLFF), Infant Breastfeeding Assessment Tool (IBFAT), classified with respect to its anatomical insertion level:14
LATCH grading scales, mandibular labial frenulum, perio- 1. mucosal (frenal fibers are attached up to the muco-
dontal indications for frenectomy, gingival recession associated gingival junction);
with midline diastema; fields: all; limits: within the last 15 2. gingival (frenal fibers are inserted within the attached
years, English. One hundred seventeen articles matched these gingiva);
criteria. Papers for review were chosen from this list and from 3. papillary (frenal fibers are extending into the inter-
references within selected articles. Expert and/or consensus dental papilla); and
opinion by experienced researchers and clinicians also was 4. papilla penetrating (frenal fibers cross the alveolar
considered. process and extend up to the palatine papilla).
Definitions The most commonly observed types are mucosal and

Frenectomy: excision of the frenulum left to heal by secondary gingival.9 However, a maxillary frenulum is a dynamic structure
intention. that presents changes in position of insertion, structure, and
Frenotomy: simple cutting or incision of the frenulum. shape during growth and development.9 Infants have the high-
Frenuloplasty: excisions involving sutures releasing the frenulum est prevalence of papillary penetrating phenotype.9 In severe
and correcting the anatomic situation. instances, a restrictive maxillary frenulum attachment has been
associated with breastfeeding and bottle-feeding difficulties
among newborns in a number of studies. 16-19 It has been

suggested that a restrictive maxillary frenulum may inhibit an when treatment of the frenulum is considered due to higher
airtight seal on the maternal breast through “flanging” of both caries risk, anticipatory guidance and other preventive mea-
lips.12,17-19 The maxillary frenulum can contribute to reflux in sures should be emphasized.
babies due to the intake of air from a poor seal at the breast
or bottle leading to colic or irritability.19,20 With the lack Lingual frenulum
of understanding of the function of the labial frenulum, the The World Health Organization has recommended mothers
universality of the labial frenulum, and level of attachment in worldwide exclusively breastfeed infants for the child’s first
most infants, therelease of the maxillary frenulum based on six months to achieve optimum growth, development, and
appearance alone cannot be endorsed at this time.21 A hyper- health. 27 Thereafter, they should be given complementary
plastic labial frenulum that inserts into the free or marginal foods and continue breastfeeding up to the age of two years
gingiva has been suggested to interfere with proper oral hygiene or beyond.27 The American Academy of Pediatrics in 2018
measures, potentially leading to facial-cervical caries as well as reaffirmed its recommendation of exclusive breastfeeding for
initiation and progression of gingival/periodontal disease.22 To about six months, followed by continued breastfeeding as
date, no evidence supports this conclusion although anecdotal complementary foods are introduced, with continuation of
speculation persists. Further research is required to substantiate breastfeeding for one year or longer as mutually desired by
this cause-and-effect relationship. When release of the maxillary mother and child.28 Lingual frenula, in addition to the maxil-
frenulum is considered due to higher caries risk, anticipatory lary labial frenula, have been associated by some practitioners
guidance and other preventive measures should be emphasized with impedance to successful breastfeeding, thereby leading to
first. recommendations for frenotomy. The most common symp-
Surgical removal of the maxillary midline frenulum also is toms babies and mothers experience from tongue- and lip-tie
related to presence or prevention of midline diastema forma- are poor or shallow latch on the breast or bottle, slow or poor
tion, prevention of post orthodontic relapse, esthetics, and weight gain, reflux and irritability from swallowing excessive
psychological considerations.7-9,23 Treatment options for mid- air, prolonged feeding time, milk leaking from the mouth
line diastema and sequence of care vary with patient age and from a poor seal, clicking or smacking noises when nursing/
can include orthodontics, restorative dentistry, frenectomy, or feeding, and painful nursing.19,29
a combination of these.23 Treatment is suggested (1) when the
attachment exerts a traumatic force on the gingiva causing the Ankyloglossia (tongue-tie)
papilla to blanch when the upper lip is pulled, or (2) if the Ankyloglossia is a congenital developmental anomaly of the
attachment causes a diastema wider than two millimeters, tongue characterized by a short, thick lingual frenulum result-
which is known to rarely close spontaneously during further ing in limitation of tongue movement (partial ankyloglossia)
development.9,23,24 When a diastema persists into the perma- or by the tongue appearing to be fused to the floor of the
nent dentition, the objectives for treatment involve managing mouth (total ankyloglossia).6,30 Studies with different diagnostic
both the diastema and its etiology.23 If orthodontic treatment criteria report prevalence of ankyloglossia between four and
is indicated, the need for surgical management of a frenulum 10.7 percent of the population.4,5 Several diagnostic classifica-
should be assessed and coordinated with orthodontic closure tions have been proposed based on anatomical and functional
of the diastema to achieve stable results.23-25 There is general criteria, but none has been universally accepted.4 The tongue’s
agreement between pediatric dentists and orthodontists that ability to elevate rather than protrude is the most important
a frenectomy should not be performed before the permanent quality for nursing, feeding, speech, and development of the
canines erupt and that the operation should follow orthodontic dental arch.31,32
closure of the space.26 Ankyloglossia has been associated with breastfeeding and
bottle-feeding difficulties among neonates, limited tongue
Mandibular labial frenulum mobility and speech difficulties, malocclusion, and gingival
A high frenulum sometimes can present on the labial aspect recession.3-10,24 A short frenulum can inhibit tongue movement
of the mandibular ridge. This most often is seen in the perma- and create deglutition problems. 4,33,34 During breastfeeding,
nent central incisor area and frequently occurs in individuals a restrictive frenulum can cause ineffective latch, inadequate
having a shallow vestibule.6 The mandibular labial frenulum milk transfer and intake, and persistent maternal nipple pain,
occasionally inserts into the free or marginal gingival tissue.6 all of which can affect feeding adversely and lead to early ces-
Movements of the lower lip can cause the frenulum to pull on sation of breastfeeding.3-11,24,30,33-36 Systematic literature review
the fibers inserted into the free marginal tissue, which creates articles acknowledge the role of frenotomy/frenectomy for
pocket formation that in turn, can lead to food and plaque demonstrable frenal constriction in order to reduce maternal
accumulation.6 Early treatment can be considered to prevent nipple pain and improve successful breastfeeding when the
subsequent inflammation, recession, pocket formation, and procedure is provided in conjunction with support of other
possible loss of alveolar bone and/or teeth.6 However, if factors allied healthcare professionals.4-7,10,37
causing gingival/periodontal inflammation are controlled, the Limitations in tongue mobility and speech pathology have
degree of recession and need for treatment decreases.4,6 Again, been associated with ankyloglossia. 4,38,39 However, opinions

vary among health care professionals regarding the correlation and increased patient acceptance.46 These procedures require
between ankyloglossia and speech disorders. Speech articula- extensive training as well as skillful technique and patient
tion is largely perceptual in nature, and differences in pro- management.4,9,10,39,44,47-50 As with all surgical procedures, an
nunciation often are evaluated subjectively. Variability in the informed consent should be obtained. Informed consent in-
speech assessment outcomes among individuals and specialists cludes relevant information regarding assessment, diagnosis,
from different medical backgrounds is very high. 10 The nature and purpose of proposed treatment, and potential
difficulties in articulation for individuals with ankyloglossia benefits and risks of the proposed treatment, along with
are evident for consonants and sounds like /s/, /z/, /t/, /d/, /l/, professionally-recognized or evidence-based alternative treat-
/sh/, /ch/, /th/, and /dg/, and it is especially difficult to roll ment options – including no treatment – and their risks.51
an r.10,38 Because parents often do not report speech issues
accurately, an evaluation by a speech-language pathologist Policy statement
trained in assessing tongue-ties is recommended to assess for Recognizing evidence is limited, the American Academy of
speech or language errors prior to recommending a tongue-tie Pediatric Dentistry supports additional research on the
release.40 Speech therapy in conjunction with frenuloplasty, causative association between ankyloglossia and breastfeeding
frenotomy, or frenectomy can be a treatment option to improve difficulties or speech articulation problems and between
tongue mobility and speech.38,39 Nevertheless, further evidence hyperplastic labial frenulum and increased risk of caries or
is needed to determine the benefit of surgical correction of periodontal disease due to interference with adequate oral
ankyloglossia and its relation to speech pathology as many hygiene. Further randomized controlled trials and other pro-
children and individuals with ankyloglossia are able to com- spective studies of high methodological quality are necessary
pensate and do not appear to suffer from speech difficulty.4,7,41 to determine the effects of frenotomy/frenectomy. With all
Evidence to show that ankyloglossia and abnormal tongue surgical procedures, an informed consent is necessary. Informed
position may affect skeletal development and be associated consent includes relevant information regarding assessment,
with Class III malocclusion is limited.34,42 A high-arched palate diagnosis, nature and purpose of proposed treatment, and
and elongated soft palate have been associated with tongue- potential benefits and risks of the proposed treatment, along
tie. 31,32 A complete orthodontic evaluation, diagnosis, and with professionally-recognized or evidence-based alternative
treatment plan are necessary prior to any surgical intervention.42 treatment options – including no treatment – and their risks.51
Localized gingival recession on the lingual aspect of the
mandibular incisors has been associated with ankyloglossia in References
some cases where frenal attachment causes gingival retraction.4,6 1. Canadian Agency for Drugs for Drugs and Technologies
As with most periodontal conditions, elimination of plaque- in Health. Frenectomy for the correction of ankylo-
induced gingival inflammation can minimize gingival recession glossia: A review of clinical effectiveness and guidelines.
without any surgical intervention.4 When recession continues CADTH Rapid Response Reports; 2016 Jun 15. Available
even after oral hygiene management, surgical intervention may at: “https://www.ncbi.nlm.nih.gov/books/NBK373454/”.
be indicated.4,6 Accessed July 1, 2019.
2. Walsh J, Links A, Boss E, Tunkel D. Ankyloglossia and
Treatment considerations lingual frenectomy: National trends in inpatient diag-
Although evidence in the literature to promote the timing, nosis and management in the United States, 1997-2012.
indication, and type of surgical intervention is limited, Otolaryngal Head Neck Surg 2017;156(4):735-40.
frenotomy/frenectomy for functional limitations and symp- 3. Delli K, Livas C, Sculean A, Katsaros C, Bornstein M.
tomatic relief should be considered on an individual basis.4,10, Facts and myths regarding the maxillary midline frenum
34,36,39,43
When indicated, frenuloplasty, frenectomy, and freno- and its treatment: A systematic review of the literature.
tomy may be a successful approach in alleviating the problem.4,9, Germany Quintessence Int 2013;44(2):177-87.
10,44
Each of these procedures involves surgical incision or 4. Segal L, Stephenson R, Dawes M, Feldman P. Prevalence,
excision, establishing hemostasis, and wound management.45 diagnosis, and treatment of ankyloglossia. Can Fam
Dressing placement or the use of antibiotics is not necessary.45 Physician 2007;53(6):1027-33.
Post-operative recommendations include maintaining a soft 5. Boutsi EZ, Tatakis DN. Maxillary labial frenum attach-
diet, regular oral hygiene, and analgesics as needed. Post- ment in children. Int J Paediatr Dent 2011;21(4):284-8.
operative exercises are necessary to prevent reattachment of 6. John J, Weddell JA, Shin DE, Jones JJ. Gingivitis and
the wound and relapse of the previous symptoms associated periodontal disease. In: JA Dean, ed. McDonald and
with the tongue or lip-tie.29,42 Avery’s Dentistry for the Child and Adolescent, 10th ed.
The use of electrosurgery or laser technology for frenotomies/ Maryland Heights, Mo.: Mosby Elsevier; 2016:243-73.
frenectomies has demonstrated a shorter operative working 7. Finigan V, Long T. The effectiveness of frenulotomy on
time, a better ability to control bleeding, reduced intra- and infant-feeding outcomes: A systemic literature review.
post-operative pain and discomfort, fewer postoperative com- Evidence Based Midwifery 2013;11(2):40-5.
plications (e.g., swelling, infection), no need for suture removal,

8. O’Callahan C, Macary S, Clemente S. The effects of 23. Gkantidis N, Kolokitha OE, Topouzelis N. Management
office-based frenotomy for anterior and posterior ankylo- of maxillary midline diastema with emphasis on etiology.
glossia on breastfeeding. Int J Pediatr Otorhinolaryngol J Clin Pediatr Dent 2008;32(4):265-72.
2013;77(5):827-32. 24. Ochi J. Treating tongue-tie: Assessing the relationship
9. Webb AN, Hao W, Hong P. The effect of tongue-tie between frenotomy and breastfeeding symptoms. Clin
division on breastfeeding and speech articulation: A Lactation 2014;5(1):20-7.
systematic review. Int J Pediatr Otorhinolaryngol 2013; 25. Mallya SM, Lurie AG. Panoramic imaging. In: White S,
77(5):635-46. Pharoah M, eds. Oral Radiology: Principles and Inter-
10. Suter VG, Bornstein MM. Ankyloglossia: Facts and myths pretation. 7th ed. St. Louis, Mo.: Mosby Elsevier; 2014:
in diagnosis and treatment. J Periodontol 2009;80(8): 166-84.
1204-19. 26. Wheeler B, Carrico CK, Shroff B, Brickhouse T, Laskin
11. Huang W, Creath C. The midline diastema: A review of its DM. Management of the maxillary diastema by various
etiology and treatment. Pediatr Dent 1995;17(3):171-7. dental specialties. J Oral Maxillofac Surg 2018;76(4):
12. Knox I. Tongue tie and frenotomy in the breastfeeding 709-15.
newborn. Neo Reviews 2010;11(9):e513-9. 27. World Health Organization. Breastfeeding. Geneva:
13. Walsh J, Tunkel D. Diagnosis and treatment of ankylo- World Health Organization; 2016. [cited 2016 Jun 2].
glossia in newborns and infants: A review. JAMA Available at: “http://www.who.int/topics/breastfeeding/
Otolaryngol Head Neck Surg 2017;143(10):1032-9.
14. Priyanka M, Sruthi R, Ramakrishnan T, Emmadj P,
en/”. Accessed July 1, 2019. (Archived by WebCite at: ®
“http://www.webcitation.org/74oi8YxBV”)
Ambalavanan N. An overview of frenal attachments. J 28. American Academy of Pediatrics. Breastfeeding and the
Indian Soc Periodontol 2013;17(1):12-5. use of human milk. Pediatrics 2012;129(3):e827-e841.
15. Mintz SM, Siegel MA, Seider PJ. An overview of oral 29. Ghaheri B, Cole M, Mace J. Revision lingual frenotomy
frena and their association with multiple syndromes and improves patient-reported breastfeeding outcomes: A
nonsyndromic conditions. Oral Surg Oral Med Oral prospective cohort study. J Hum Lact 2018;34(3):
Pathol Oral Radio/Endo 2005;99(3):321-4. 566-74.
16. Neville BW, Damm DD, Allen CM, Chi AC. Develop- 30. Amir L, James J, Beatty J. Review of tongue-tie release
mental defects of the oral and maxillofacial region. In: at a tertiary maternity hospital. J Paediatr Child Health
Oral and Maxillofacial Pathology, 4th ed. St. Louis, Mo: 2005;41(5-6):243-5.
Saunders Elsevier; 2016:9-10. 31. Yoon A, Zaghi S, Ha S, Law C, Guilleminault C, Liu S.
17. Coryllos E, Genna CW, Salloum A. Congenital tongue- Ankyloglossia as a risk factor for maxillary hypoplasia and
tie and its impact on breastfeeding. In: Breastfeeding: soft tissue elongation: A functional-morphological study.
Best for baby and mother. Am Acad Pedia (newsletter) Orthod Craniofac Res 2017;20(4):237-44.
2004;Summer:1-7. 32. Yoon A, Zaghi S, Weitzman R, Ha S, Law C, Guilleminault
18. Pransky S, Lago D, Hong P. Breastfeeding difficulties and C, Liu S. Toward a functional definition of ankyloglossia:
oral cavity anomalies: The influence of posterior ankylo- Validating current grading scales for lingual frenulum
glossia and upper-lip ties. Int J Pediatr Otorhinolaryngol length and tongue mobility in 1052 subjects. Sleep Breath
2015;79(10):1714-7. 2017;21(3):767-75.
19. Ghaheri B, Cole M, Fausel S, Chuop M, Mace J. Breast- 33. Dollberg S, Botzer E, Guins E, Mimouni F. Immediate
feeding improvement following tongue-tie and lip-tie nipple pain relief after frenotomy in breast-fed infants
release: A prospective cohort study. Laryngoscope 2017; with ankyloglossia: A randomized, prospective study. J
127(5):1217-23. Pediatr Surg 2006;41(9):1598-600.
20. Seigal S. Aerophagia induced reflux in breastfeeding 34. Geddes D, Langton D, Gollow I, Jacobs L, Hartmann P,
infants with ankyloglossia and shortened maxillary labial Simmer K. Frenulotomy for breastfeeding infants with
frenula (tongue and lip tie). Int J Pediatr 2016;5(1):6-8. ankyloglossia: Effect on milk removal and sucking mech-
21. Santa Maria C, Abby J, Truong MT, Thakur Y, Rea anism as imaged by ultrasound. Pediatrics 2008;122(1):
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22. Minsk L. The frenectomy as an adjunct to periodontal glossia in breastfeeding infants: The effects of frenotomy
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37. O’Shea JE, Foster JP, O’Donnell, et al. Frenectomy for 45. Kaban L, Troulis M. Intraoral soft tissue abnormalities.
tongue-tie in newborn infants. Cochrane Library-Wiley In: Pediatric Oral and Maxillofacial Surgery. Philadelphia,
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wiley.com/doi/10.1002/14651858.CD011065.pub2/full”. 46. Olivi G, Chaumanet G, Genovese MD, Beneduce C,
Accessed August 10, 2019. Andreana S. Er,Cr:YSGG laser labial frenectomy: A
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127(6):539-45. 47. Hogan M, Wescott C, Griffiths M. Randomized, controlled
39. Kupietzky A, Botzer E. Ankyloglossia in the infant and trial of division of tongue-tie in infants with feeding
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management. Pediatr Dent 2005;27(1):40-6. 48. Díaz-Pizán M, Lagravère M, Villena R. Midline diastema
41. Kummer AW. Ankyloglossia: To clip or not to clip? and frenum morphology in the primary dentition. J Dent
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40. Hazelbaker AK. Impact: speech and orofacial considera- 49. Gontijo I, Navarro R, Haypek P, Ciamponi A, Haddad A.
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Dent Res 2012;6(9):1587-92.

ORAL HEALTH POLICIES: ECC: CLASSIFICATION, CONSEQUENCES, PREVENTIVE STRATEGIES
Policy on Early Childhood Caries (ECC): Classifications,

Consequences, and Preventive Strategies
2016 early childhood caries (ECC): Classifications, consequences, and
preventive strategies. The Reference Manual of Pediatric Dentistry.
Purpose the age of six. The definition of severe early childhood caries
Early childhood caries (ECC), formerly referred to as nursing (S-ECC) is any sign of smooth-surface caries in a child
bottle caries and baby bottle tooth decay, remains a signifi- younger than three years of age, and from ages three through
cant public health problem.1 The American Academy of five, one or more cavitated, missing (due to caries), or filled
Pediatric Dentistry (AAPD) encourages healthcare providers smooth surfaces in primary maxillary anterior teeth or a de-
and caregivers to implement preventive practices that can cayed, missing, or filled score of greater than or equal to four
decrease a child’s risks of developing this disease. (age 3), greater than or equal to five (age 4), or greater than
or equal to six (age 5).4
Methods Epidemiologic data from a 2011-2012 national survey
This policy was developed in a collaborative effort of the clearly indicate that ECC remains highly prevalent in poor and
American Academy of Pedodontics and the American near poor U.S. preschool children. For the overall population
Academy of Pediatrics (AAP), and adopted in 1978. This of preschool children, the prevalence of ECC, as measured by
document is a revision of the previous version, last revised decayed and filled tooth surfaces (dfs), is unchanged from
by the AAPD in 2014. The update used electronic and hand previous surveys, but the filled component (fs) has greatly
searches of English written articles in the dental and medical increased indicating that more treatment is being provided.5
literature within the last 10 years, using the search terms in- The consequences of ECC often include a higher risk of new
fant oral health, infant oral health care, and early childhood carious lesions in both the primary and permanent denti-
caries. Recent references to ECC, along with full text, can be tions, 6,7 hospitalizations and emergency room visits, 8,9 high
found on the Early Childhood Caries Resource Center data- treatment costs,10 loss of school days,11 diminished ability to
base (http://earlychildhoodcariesresourcecenter.elsevier.com). learn,12 and diminished oral health-related quality of life.13
When information from these articles did not appear suffi- Microbial risk markers for ECC include MS and Lacto-
cient or was inconclusive, policies were based upon expert and bacillus species.14 However, new tools for bacterial identifi-
consensus opinion by experienced researchers and clinicians. cation (e.g., polymerase chain reaction techniques, 16s rRNA
gene sequencing) are revealing the complexity of the oral mi-
Background crobiome and other bacterial species that may be associated
In 1978, the American Academy of Pedodontics and the with ECC.15 MS maybe transmitted vertically from caregiver
AAP released a joint statement Juice in Ready-to-Use Bottles to child through salivary contact, affected by the frequency
and Nursing Bottle Caries to address a severe form of caries and amount of exposure.16 Infants whose mothers have high
associated with bottle usage.2 Initial policy recommendations levels of MS, a result of untreated caries, are at greater risk of
were limited to feeding habits, concluding that nursing bottle acquiring the organism earlier than children whose mothers
caries could be avoided if bottle feedings were discontinued have low levels.17 Horizontal transmission (e.g., between other
soon after the first birthday. An early policy revision added members of a family or children in daycare) also occurs.17
ad libitum breast-feeding as a causative factor. Over the An associated risk factor to microbial etiology is high
next two decades, however, recognizing that ECC was not consumption of sugars.18 Caries-conducive dietary practices
solely associated with poor feeding practices, AAPD adopted appear to be established by 12 months of age and are
the term ECC to better reflect its multi-factoral etiology. maintained throughout early childhood. 19 Frequent night-
These factors include susceptible teeth due to enamel hypo- time bottle-feeding with milk and ad libitum breast-feeding
plasia, oral colonization with elevated levels of cariogenic
bacteria, especially Mutans streptococci (MS), and the
metabolism of sugars by tooth-adherent bacteria to produce ABBREVIATIONS
acid which, over time, demineralizes tooth structure.3
AAPD: American Academy Pediatric Dentistry. AAP: American
ECC is defined as the presence of one or more decayed Academy of Pediatrics. ECC: Early childhood caries. mg: Milligram.
(noncavitated or cavitated lesions), missing (due to caries), MS: Mutans streptococci.
or filled tooth surfaces in any primary tooth in a child under

are associated with, but not consistently implicated in, ECC.20 in many cases, are being trained to provide oral screenings,
Night time bottle feeding with juice, repeated use of a sippy apply preventive measures, counsel caregivers, and refer infants
or no-spill cup, and frequent in-between meal consumption and toddlers for dental care.32
of sugar-added snacks or drinks (e.g., juice, formula, soda)
increase the risk of caries.21 While ECC may not arise from Policy statement
breast milk alone, breast-feeding in combination with other The AAPD recognizes early childhood caries as a significant
carbohydrates has been found in vitro to be highly cariogenic.22 chronic disease resulting from an imbalance of multiple risk
Frequent consumption of between-meal snacks and beverages and protective factors over time. To decrease the risk of
containing sugars increases the risk of caries due to prolonged developing ECC, the AAPD encourages professional and at-
contact between sugars in the consumed food or liquid and home preventive measures that include:
cariogenic bacteria on the susceptible teeth. 23 The AAP has 1. avoiding frequent consumption of liquids and/or solid
recommended that infants should not be given juice from foods containing sugar, in particular:
bottles or covered cups that allow them to consume juice a. sugar-sweetened beverages (e.g., juices, soft drinks,
throughout the day, and intake of 100 percent fruit juice sports drinks, sweetened tea) in a baby bottle or
should be limited to no more than four to six ounces per no-spill training cup.
day for children one through six years old.24 Additionally, b. ad libitum breast-feeding after the first primary tooth
newly-erupted teeth, because of immature enamel, and teeth begins to erupt and other dietary carbohydrates are
with enamel hypoplasia may be at higher risk of developing introduced.
caries.25 c. baby bottle use after 12-18 months.
Current best practice to reduce the risk of ECC includes 2. implementing oral hygiene measures no later than the
twice-daily brushing with fluoridated toothpaste for all time of eruption of the first primary tooth. Toothbrush-
children in optimally-fluoridated and fluoride-deficient coming should be performed for children by a parent twice
munities.26,27 When determining the risk-benefit of fluoride, daily, using a soft toothbrush of age-appropriate size.
the key issue is mild fluorosis versus preventing dental disease. In children under the age of three, a smear or rice-sized
A smear or rice-sized amount of fluoridated toothpaste amount of fluoridated toothpaste should be used. In
(approximately 0.1 milligram (mg) fluoride; see Figure) should children ages three to six, a pea-sized amount of fluoridated
be used for children less than three years of age. A pea-sized toothpaste should be used.
amount of fluoridated toothpaste (approximately 0.25 mg 3. providing professionally-applied fluoride varnish treat-
fluoride) is appropriate for children aged three to six.28 Parents ments for children at risk for ECC.
should dispense the toothpaste onto a soft, age-appropriate 4. establishing a dental home within six months of eruption
sized toothbrush and perform or assist with toothbrushing of of the first tooth and no later than 12 months of age to
preschool-aged children. To maximize the beneficial effect of conduct a caries risk assessment and provide parental
fluoride in the toothpaste, rinsing after brushing should be education including anticipatory guidance for prevention
kept to a minimum or eliminated altogether.29 of oral diseases.
Professionally-applied topical fluoride treatments also are 5. working with medical providers to ensure all infants and
efficacious in reducing prevalence of ECC. The recommend- toddlers have access to dental screenings, counseling, and
ed professionally-applied fluoride treatments for children at preventive procedures.
risk for ECC who are younger than six years is five percent 6. educating legislators, policy makers, and third-party
sodium fluoride varnish (NaFV; 22,500 parts per million F).30 payors regarding the consequences of and preventive
Evidence increasingly suggests that preventive interven- strategies for ECC.
tions within the first year of life are critical. 31 This may be
best implemented with the help of medical providers who, References
1. Tinanoff N. Introduction to the conference: Innovations
in the prevention and management of early childhood
Smear – under 3 yrs. Pea-sized – 3 to 6 yrs. caries. Pediatr Dent 2015;37(3):198-9.
2. American Academy of Pediatrics, American Academy of
Pedodontics. Juice in ready-to-use bottles and nursing
bottle caries. AAP News and Comment 1978;29(1):11.
3. Tinanoff N. Introduction to the conference: Innovations
in the prevention and management of early childhood
caries. Pediatr Dent 2015;37(4):198-9.
4. Drury TF, Horowitz AM, Ismail AI, et al. Diagnosing and
reporting early childhood caries for research purposes.
Figure. Comparison of a smear (left) with a pea-sized (right) amount J Public Health Dent 1999;59(3):192-7.
of toothpaste.

5. Dye BA, Hsu K-L, Afful J. Prevalence and measurement 19. Kranz S, Smiciklas-Wright H, Francis LA. Diet quality,
of dental caries in young children. Pediatr Dent 2015; added sugar, and dietary fiber intake in American
37(3):200-16. preschoolers. Pediatr Dent 2006;28(2):164-71.
6. O’Sullivan DM, Tinanoff N. The association of early 20. Reisine S, Douglass JM. Psychosocial and behavioral
childhood caries patterns with caries incidence in issues in early childhood caries. Comm Dent Oral
preschool children. J Public Health Dent 1996;56(2): Epidem 1998;26(suppl 1):32-44.
81-3. 21. Tinanoff NT, Kanellis MJ, Vargas CM. Current under-
7. Al-Shalan TA, Erickson PR, Hardie NA. Primary incisor standing of the epidemiology mechanism, and prevention
decay before age 4 as a risk factor for future dental of dental caries in preschool children. Pediatr Dent 2002;
caries. Pediatr Dent 1997;19(1):37-41. 24(6):543-51.
8. Ladrillo TE, Hobdell MH, Caviness C. Increasing 22. Erickson PR, Mazhari E. Investigation of the role of
prevalence of emergency department visits for pediatric human breast milk in caries development. Pediatr Dent
dental care 1997-2001. J Am Dent Assoc 2006;137(3): 1999;21(2):86-90.
379-85. 23. Tinanoff NT, Palmer C. Dietary determinants of dental
9. Griffin SO, Gooch BF, Beltran E, Sutherland JN, Barsley caries in preschool children and dietary recommendations
R. Dental services, costs, and factors associated with for preschool children. J Pub Health Dent 2000;60(3):
hospitalization for Medicaid-eligible children, Louisiana 197-206.
1996-97. J Public Health Dent 2000;60(3):21-7. 24. American Academy of Pediatrics Committee on Nutri-
10. Agency for Healthcare Research and Quality. Total tion. Policy statement: The use and misuse of fruit juices
dental care expenditure, 2010, Medical Expenditure in pediatrics. Pediatrics 2001;107(5):1210-3. Reaffirmed
Panel Survey. Available at: “http://meps.ahrq.gov/meps October, 2006.
web/data_files/publications/st415/stat415.pdf ”. Accessed 25. Caufield PW, Li Y, Bromage TG. Hypoplasia-associated
webcitation.org/6XezI3w7Y”)
®
April 9, 2015. (Archived by WebCite at: “http://www. severe early childhood caries: A proposed definition. J
Dent Res 2012;91(6):544-50.
11. Edelstein BL, Reisine S. Fifty-one million: A mythical 26. Santos AP, Oliveira BH, Nadanovsky P. Effects of low
number that matters. J Am Dent Assoc 2015;146(8): and standard fluoride toothpastes on caries and fluorosis:
565-6. Systematic review and meta-analysis. Caries Res 2013;
12. Blumenshine SL, Vann WF, Gizlice Z, Lee JY. Children’s 47(5):382-90.
school performance: Impact of general and oral health. 27. American Dental Association Council on Scientific
J Public Health Dent 2008;68(2):82-7. Affairs. Fluoride toothpaste use for young children. J
13. Filstrup SL, Briskie D, daFonseca M, Lawrence L, Wandera Am Dent Assoc 2014;145(2):190-1.
A, Inglehart MR. The effects on early childhood caries 28. Wright JT, Hanson N, Ristic H, Whall CW, Estrich
(ECC) and restorative treatment on children’s oral CG, Zentz RR. Fluoride toothpaste efficacy and safety
health-related quality of life (OHRQOL). Pediatr Dent in children younger than 6 years. J Am Dent Assoc 2014;
2003;25(5):431-40. 145(2):182-9.
14. Kanasi E, Johansson J, Lu SC, et al. Microbial risk 29. Sjögren K, Birkhed D. Factors related to fluoride reten-
markers for childhood caries in pediatrician’s offices. J tion after toothbrushing and possible connection to
Dent Res 2010;89(4):378-83. caries activity. Caries Res 1993;27(6):474-7.
15. Li Y, Tanner A. Effect of antimicrobial interactions on 30. Weyant RJ, Tracy SL, Anselmo T, Beltrán-Aguilar EJ,
the oral microbiota associated with early childhood Donly KJ, Frese WA. Topical fluoride for caries pre-
caries. Pediatr Dent 2015;37(3):226-44. vention: Executive summary of the updated clinical
16. Li Y, Caufield PW. The fidelity of initial acquisition of recommendations and supporting systematic review. J
mutans streptococci by infants from their mothers. J Am Dent Assoc 2013;144(11):1279-91.
Dent Res 1995;74(2):681-5. 31. Lee JY, Bouwens TJ, Savage MF, Vann WF. Examining
17. Berkowitz RJ. Mutans streptococci: Acquisition and the cost-effectiveness of early dental visits. Pediatr Dent
transmission. Pediatr Dent 2006;28(2):106-9. 2006;28(2):102-105, discussion 192-8.
18. Moynihan PJ, Kelly SAM. Effect on caries of restricting 32. Douglass AB, Douglass JM, Krol DM. Educating
sugars intake: Systematic review to inform WHO guide- pediatricians and family physicians in children’s oral
lines. J Dent Res 2014;93(1):8-18. health. Academic Pediatr 2009;9(6):452-6.

ORAL HEALTH POLICIES: ECC: UNIQUE CHALLENGES, TREATMENT OPTIONS
Policy on Early Childhood Caries (ECC): Unique

Challenges and Treatment Options
2016 early childhood caries (ECC): Unique challenges and treatment
options. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
Purpose 1. chronic disease management, which includes parent

The American Academy of Pediatric Dentistry (AAPD), to engagement to facilitate preventive measures, and tempo-
promote appropriate, quality oral health care for infants and rary restorations to postpone advanced restorative care;12
children with early childhood caries (ECC), must educate 2. active surveillance, which emphasizes careful monitoring
the health community and society about the unique chal- of caries progression and prevention programs in chil-
lenges and management of this disease, including the need dren with incipient lesions;13 and
for advanced preventive, restorative, and behavioral guidance 3. interim therapeutic restorations (ITR) that temporarily
techniques. restore teeth in young children until a time when tradi-
tional cavity preparation and restoration is possible.14
Methods
This policy was developed by the Council on Clinical Affairs Those children with known risk factors for ECC should
and adopted in 2000. This document is a revision of the have care provided by a practitioner who has the training and
previous version, revised in 2014. The update used electronic expertise to manage both the child and the disease process.
and hand searches of English written articles in the dental The use of anticariogenic agents, especially twice daily brush-
and medical literature within the last 10 years using the ing with fluoridated toothpaste and the frequent application
search terms infant oral health, infant oral health care, and of fluoride varnish, may reduce the risk of development and
early childhood caries. Recent references to ECC, along with progression of caries. In some children where preventive
full text, can be found on the Early Childhood Caries Re- programs are not successful, areas of demineralization and
source Center database (http://earlychildhoodcariesresource hypoplasia can rapidly develop cavitation and, if untreated,
center.elsevier.com). When information from these articles the disease process can rapidly involve the dental pulp, lead-
did not appear sufficient or was inconclusive, policies were ing to infection and possibly life-threatening fascial space
based upon expert and/or consensus opinion by experienced involvement. Such infections may result in a medical emer-
researchers and clinicians. gency requiring hospitalization, antibiotics, and extraction of
the offending tooth.15
Background The extent of the disease process as well as the patient’s
Epidemiologic data from a 2011-2012 national survey clearly developmental level and comprehension skills affect the
indicate that ECC remains highly prevalent in poor and near practitioner’s management decisions. Definitive restorative
poor U.S. preschool children.1 For the overall population of treatment in young children, in many cases, can be postponed
preschool children, the prevalence of ECC, as measured by by use of ITR or silver diamine fluoride treatments.16 For
decayed and filled tooth surfaces (dfs), is unchanged from advanced cases of ECC, the practitioner may need the aid of
previous surveys, but the filled component (fs) has greatly advanced behavior guidance techniques to complete the neces-
increased indicating that more treatment is being provided.1 sary treatment.17 Also in such situations, stainless steel crowns
The consequences of ECC often include a higher risk of new often are indicated to restore teeth with large carious lesions,
carious lesions in both the primary and permanent denti- interproximal lesions, and extensive white spot lesions since
tions,2,3 hospitalizations and emergency room visits,4,5 high stainless steel crowns are less likely than other restorations to
treatment costs,6 loss of school days,7 diminished ability to require retreatment.18 The success of restorations may be in-
learn,8 and reduced oral health-related quality of life.9 fluenced by the child’s level of cooperation during treatment,
Because restorative care to manage ECC often requires the and general anesthesia may provide better conditions to
use of sedation and general anesthesia with its associated high
costs and possible health risks,10 and because there is high
recurrence of lesions following the procedures,11 there now ABBREVIATIONS
is more emphasis on prevention and arrestment of the disease AAPD: American Academy Pediatric Dentistry. ECC: Early child-
processes. Approaches include methods that have been refer- hood caries. ITR: Interim therapeutic restorations.
red to as:

ORAL HEALTH POLICIES: ECC: UNIQUE CHALLENGES, TREATMENT OPTIONS
perform restorative procedures. General anesthesia, under cer- 10. Sinner B, Beck K, Engelhard K. General anesthetics and
tain circumstances, may offer a cost-saving alternative to the developing brain: An overview. Anesthesia 2014;69
sedation for children with ECC.19 (9):1009-22.
11. Berkowitz RJ, Amante A, Kopycka-Kedzierawski DT,
Policy statement Billings RJ, Feng C. Dental caries recurrence following
The AAPD recognizes the unique and often virulent nature clinical treatment for severe early childhood caries. Pediatr
of ECC. Non-dental healthcare providers who identify ECC Dent 2011;33(7):510-4.
in a child should refer the patient to a licensed dentist for 12. Edelstein BL, Ng MW. Chronic disease management
treatment and establishment of a dental home.20 Immediate strategies of early childhood caries: Support from the
intervention is indicated, and non-surgical interventions medical and dental literature. Pediatr Dent 2015;37(7):
should be implemented when possible to postpone or reduce 281-7.
the need for surgical treatment approaches. Because children 13. American Academy of Pediatric Dentistry. Guidelines
who experience ECC are at greater risk for subsequent caries on caries-risk assessment and management for infants,
development, preventive measures (e.g., dietary counseling, children, and adolescents. Available at: “http://http://
reinforcement of toothbrushing with fluoridated toothpaste), www.aapd.org/media/Policies_Guidelines/G_CariesRisk
more frequent professional visits with applications of topical Assessment.pdf ”. Accessed September 12, 2016. (Ar-
fluoride, and restorative care are necessary. ®
chived by WebCite at: “http://www.webcitation.org/
6tjMFA5HL”)
References 14. American Academy of Pediatric Dentistry. Policy on
1. Dye BA, Hsu K-L, Afful J. Prevalence and measurement interim therapeutic restorations (ITR). Available at:
of dental caries in young children. Pediatr Dent 2015; “http://www.aapd.org/media/Policies_Guidelines/P_ITR.
37(3):200-16. pdf ”. Accessed September 12, 2016. (Archived by Web-
2. O’Sullivan DM, Tinanoff N. The association of early
childhood caries patterns with caries incidence in pre-
®
Cite at: “http://www.webcitation.org/6tjMMxm2Q”)
15. Sheller B, Williams BJ, Lombardi SM. Diagnosis and
school children. J Public Health Dent 1996;56(2):81-3. treatment of dental caries-related emergencies in a
3. Al-Shalan TA, Erickson PR, Hardie NA. Primary incisor children’s hospital. Pediatr Dent 1997;19(8):470-5.
decay before age 4 as a risk factor for future dental caries. 16. Chu CH, Lo ECM. Promoting caries arrest in children
Pediatr Dent 1997;19(1):37-41. with silver diamine fluoride: A review. Oral Health Prev
4. Griffin SO, Gooch BF, Beltrán E, Sutherland JN, Barsley Dent 2008;6(4):15-21.
R. Dental services, costs, and factors associated with 17. American Academy of Pediatric Dentistry. Guideline on
hospitalization for Medicaid-eligible children, Louisiana behavior guidance for the pediatric dental patient. Avail-
1996-97. J Public Health Dent 2000;60(3):21-7. able at: “http://www.aapd.org/media/Policies_Guidelines/
5. Ladrillo TE, Hobdell MH, Caviness C. Increasing preval- G_BehavGuide.pdf ”. Accessed September 12, 2016.
ence of emergency department visits for pediatric dental
care 1997-2001. J Am Dent Assoc 2006;137(3):379-85.
®
org/6tjMT5GdF”)
6. Agency for Healthcare Research and Quality. Total 18. Randall RC, Vrijhoef MM, Wilson NH. Efficacy of pre-
dental care expenditure, 2010, Medical Expenditure Panel formed metal crowns vs amalgam restorations in primary
Survey. Available at: “http://meps.ahrq.gov/mepsweb/ molars: A systematic review. J Am Dent Assoc 2000;131
data_files/publications/st415/stat415.pdf ”. Accessed April (3):337-43.
citation.org/6XezI3w7Y”)
®
9, 2015. (Archived by WebCite at: “http://www.web 19. Lee JY, Vann WF, Roberts MW. A cost analysis of
treating pediatric dental patients using general anesthesia
7. Edelstein BL, Reisine S. Fifty-one million: A mythical vs conscious sedation. Pediatr Dent 2000;22(1):27-32.
number that matters. J Am Dent Assoc 2015;146(8): 20. American Academy of Pediatric Dentistry. Definition of
565-6. dental home. Available at: “http://www.aapd.org/media
8. Blumenshine SL, Vann WF, Gizlice Z, Lee JY. Children’s /Policies_Guidelines/D_DentalHome.pdf ”. Accessed
school performance: Impact of general and oral health.
J Public Health Dent 2008;68(2):82-7.
September 12, 2016. (Archived by WebCite at: “http:
//www.webcitation.org/6tjMbEJnD”)
®
9. Filstrup SL, Briskie D, daFonseca M, Lawrence L, Wan-
dera A, Inglehart MR. The effects on early childhood
caries (ECC) and restorative treatment on children’s oral
health-related quality of life (OHRQOL). Pediatr Dent
2003;25(5):431-40.

ORAL HEALTH POLICIES: DIETARY RECOMMENDATIONS
Policy on Dietary Recommendations for Infants,

Children, and Adolescents
2017 dietary recommendations for infants, children, and adolescents.
Purpose Dental caries prevalence in children has been variable, but

The American Academy of Pediatric Dentistry (AAPD) remains high. For instance, prevalence of dental caries in
recognizes its role in promoting well-balanced, low caries-risk, primary teeth for children aged 2-5 increased from 22 percent
and nutrient-dense diets for infants, children, adolescents, and to 30 percent between 1988-1994 and 1999-2004 and then
persons with special health care needs. decreased to 23 percent in 2011-2012.4 The causes of dental
caries involve a combination of factors and include diet, bac-
Methods teria capable of fermenting carbohydrates, fluoride exposure,
This policy was developed by the Clinical Affairs Committee and a susceptible host.5 While sugar, especially high frequency
and adopted in 1993. This document is an update from the consumption, is a factor contributing to dental caries, a
last revision in 2012. The current revision includes searches systematic study of sugar consumption and caries risk concluded
of articles published in English between 1995 and 2017 using that the relationship between sugar consumption and caries
® ®
PubMed /MEDLINE, Embase , and Google Scholar. Key
terms included childhood, obesity, dental caries, diet, and
is weaker after the introduction of fluoride exposure.6
The causes of obesity include genetic components, lifestyle,
nutrition. Additional terms included health education, breast- and environmental variables, as well as nutritional factors.
feeding, food habits, dietary guidelines, sugar, sugar-sweetened Health initiatives in the United States and other countries
beverages, and body mass index. After conducting the have specifically targeted reducing consumption of SSBs in
literature searches, articles were screened by viewing titles and an effort to lower the number of calories that children and
abstracts. Data from 194 articles were abstracted and used to adolescents consume per day. For children and adolescents
summarize dietary policies and research on diet and nutrition aged 2-19, the prevalence of obesity has remained constant at
for infants, children, and adolescents. about 17 percent, with obesity affecting about 12.7 million
children and adolescents for the past decade.7 Children and
Background adolescents who are obese are likely to be obese as adults
Dietary behaviors and prevalence of dental caries and and, in adulthood, at risk for health problems such as heart
obesity in children disease, type 2 diabetes, stroke, several types of cancer, and
The causes of dental caries and obesity are multifactorial, osteoarthritis.8 Because of the persistent high prevalence of
with both having significant dietary components. One of the dental caries and childhood obesity, the need remains for
behaviors associated with dental caries and obesity in children research, policy, advocacy, education, and professional engage-
is the consumption of large quantities of sugar-sweetened ment to further advance healthy dietary practices for infants,
foods and beverages. Sugar-sweetened beverages (SSBs) are children, and adolescents.
defined by the Centers for Disease Control and Prevention to
include soft drinks (soda or pop), fruit drinks, sports drinks, National and international dietary guidelines
tea and coffee drinks, energy drinks, sweetened milk or milk The U.S. Department of Health and Human Services and the
alternatives, and any other beverages to which sugar, gener- U.S. Department of Agriculture develop dietary guidelines
ally high-fructose corn syrup or sucrose (table sugar), has been every five years to help Americans aged two and older make
added.1 Sugar-containing beverages (SCBs) include SSBs as healthy food choices to help prevent chronic disease and
well as beverages in which sugar, generally glucose or fructose, enjoy a healthy diet. The 2015-2020 Dietary Guidelines for
is naturally present, such as 100 percent fruit juice. Americans8 emphasize consuming a healthy eating pattern that
Children’s and adolescent’s consumption of SSBs in the
United States is high, and it increased from 242 calories/day
between 1988-1994 to 270 calories/day between 1999-2004.2 ABBREVIATIONS
Additionally, adolescents with low-educated parents have AAP: American Academy of Pediatrics. AAPD: American Academy
higher total SSBs consumption and higher energy intake from Pediatric Dentistry. OTC: Over-the-counter. SCBs: Sugar-containing
beverages. SSBs: Sugar-sweetened beverages.
SSBs.3

includes a variety of vegetables, fruits, grains, fat-free or low- medications, most commonly as analgesics, antipyretics, and
fat dairy products, a variety of protein foods, and oils, with cough and cold medications.16 Numerous OTC and prescribed
limits on saturated and trans fats, added sugars, and sodium. oral liquid medications have been found to have a high sugar
The Dietary Guidelines for Americans give specific quantitative content to increase palatability and acceptance by children.17-19
guidelines for consumers, such as consuming less than 10 Frequent ingestion of sugar-sweetened medications is asso-
percent of calories per day from added sugars, consuming less ciated with dental caries in chronically ill children.17,18,20 To
than 10 percent of calories per day from saturated fats, and motivate children to consume vitamins, numerous companies
consuming less than 2,300 milligrams per day of sodium.8 In have made sugar containing jelly, gummy, and candy-like
addition, the World Health Organization recommends reducing chewable vitamin supplements, and cases of vitamin A toxicity
the intake of sugar to less than 10 percent of total energy have been reported as a result of excessive consumption of
intake, and to reduce children’s risk of weight gain and dental candy-like vitamin supplements.21 The AAP has recommended
caries, limiting the intake of sugar to less than five percent that the optimal way to obtain adequate amounts of vitamins
of total energy intake per day (less than 16 grams of sugar is to consume a healthy and well-balanced diet.22
for children aged 4-8).9 Additionally, the American Heart With regard to obesity, oral health professionals need to
Association recommends reducing sugar consumption in be more engaged in identifying children at risk for obesity
children and adolescents to less than 25 grams of added sugar and provide appropriate referral to pediatricians or nutri-
per day.10 One should note that eight ounces of soft drink tional specialists. A 2016 survey of pediatric dentists reported
contain approximately 26 grams of sugar. that 17 percent offer childhood obesity interventions, while
94 percent offer information or other interventions on the
Dietary recommendations in dental practice consumption of sugar sweetened beverages. 23 Barriers to
Dietary choices affect oral health as well as general health and providing healthy weight interventions including fear of
well-being. Establishment of a dental home by 12 months of offending the parent, appearing judgmental, creating parent
age allows the institution of individualized caries-preventive dissatisfaction, and lack of parental acceptance of advice about
strategies, including dietary recommendations and appropriate weight management from a dentist.23
oral hygiene instruction, as the primary teeth begin to erupt.11
Epidemiological research shows that human milk and Policy statement
breast-feeding of infants provide general health, nutritional, The AAPD supports:
developmental, psychological, social, economic, and environ- • The recommendation of national and international
mental advantages while significantly decreasing risk for a organizations to reduce the consumption of sugar to less
large number of acute and chronic diseases. 12 A systematic than 10 percent of total energy intake and, to reduce chil-
review of cariogenic potential of milk and infant formulas in dren’s risk of weight gain and dental caries, sugar intake
animal models found that cow’s milk and human milk are should be less than five percent of total energy intake
less cariogenic than sucrose solutions.13 Another systematic (less than 16 grams of sugar for children aged 4-8).
review concluded that children exposed to long durations • Breast-feeding of infants prior to 12 months of age to
of breast-feeding up to age 12 months had reduced risk of ensure the best possible health and developmental and
caries. However, children breastfed more than 12 months psychosocial outcomes for infants.
has an increased risk of caries; and those children breastfed
• The AAP recommendations on fruit juice in infants,
nocturnally or more frequently had a further increased caries
children, and adolescents.
risk.14
• Education of health professionals and parents regarding
A June, 2017 recommendation of the Committee on
daily sugar-consumption recommendations, as well as
Nutrition of the American Academy of Pediatrics (AAP) has
the sugar content of foods, beverages and oral liquid
reaffirmed that 100 percent juice and juice drinks have no
essential role in a healthy diet for children, and contribute medications.
to excessive calorie intake and risk of dental caries in chil- • Dental professionals becoming more engaged in identi-
dren.15 Their recommendations include: juice should not be fying children who consume frequent or large quantities
introduced to infants before one year of age; intake of juice of sugar-containing foods and beverages, and who are at
should be limited to four ounces a day for children ages 1-3 risk for dental caries and obesity.
years of age; 4-6 ounces for children 4-6 years of age; eight • Dental professionals’ engagement in nutrition education
ounces for children 7-18 years of age; toddlers should not and provision, when necessary, of appropriate referral for
be given juice in containers that foster easy consumption; and dietary counseling from pediatrician or nutritional
toddlers should not be given juice at bedtime.15 specialist.
It has been shown that nearly 54 percent of U.S. preschool
children were given some form of over-the-counter (OTC) References on the next page.

References 10. Vos MB, Kaar JL, Welsh JA, et al. Added sugars and
1. Centers for Disease Control and Prevention. The CDC cardiovascular disease risk in children: A scientific state-
guide to strategies for reducing the consumption of ment from the American Heart Association. Circulation
sugar-sweetened beverages. Available at: “http://www. 2017;135(19):e1017-e1034.
cdph.ca.gov/SiteCollectionDocuments/StratstoReduce_ 11. American Academy of Pediatric Dentistry. Policy on the
Sugar_Sweetened_Bevs.pdf ”. Accessed March 21, 2017. dental home. Pediatr Dent 2017;39(6):29-30.
(Archived by WebCite® at: “http://www.webcitation.org/ 12. American Academy of Pediatrics. Policy statement: Breast-
6p8T5uXrT”) feeding and the use of human milk. Pediatrics 2012;129
2. Wang YC, Bleich SN, Gortmaker SL. Increasing caloric (3):e827-41.
contribution from sugar-sweetened beverage, and 100 13. Aarthi J, Muthu S, Sujatha S. Cariogenic potential of
percent fruit juices among US children and adolescents, milk and infant formulas: A systematic review. Eur Arch
1988-2004. Pediatr 2008;121(6):e1604-14. Paediatr Dent 2013;14(5):289-300.
3. Han E, Powell LM. Consumption patterns of sugar- 14. Tham R, Bowatte G, Dharmage SC, et al. Breastfeeding
sweetened beverages in the United States. J Acad Nutr and the risk of dental caries: A systematic review and
Diet 2013;113(1):43-53. meta-analysis. Acta Paediatr 2015;104(467):62-84.
4. Dye BA, Hsu KL, Afful J. Prevalence and measurement 15. Heyman MB, Abrams SA. Fruit juice in infants, children,
of dental caries in young children. Pediatr Dent 2015; and adolescents: Current recommendations. Pediatrics
37(3):200-16. 2017;139(6):1-8.
5. Slayton RL, Fontana M, Young D, et al. Dental caries 16. Kogan MD, Pappas G, Yu SM, Kotelchuck M. Over-the-
management in children and adults. Institute of Medi- counter medication use among US preschool children. J
cine, 2016; National Academy of Medicine, Washington, Am Med Assoc 1994;272(13):1025-30.
D.C. Available at: “https://nam.edu/dental-caries-manage 17. Kenny DJ, Somaya P. Sugar load of oral liquid medica-
ment-in-children-and-adults/”. Accessed March 21, 2017. tions on chronically ill children. J Can Dent Assoc 1989;
(Archived by WebCite® at: “http://www.webcitation.org/ 55(1):43-6.
6p8Spd8l9”) 18. Maguire A, Rugg-Gunn AJ, Butler TJ. Dental health of
6. Burt BA, Satishchandra P. The relationship between low children taking antimicrobial and non-antimicrobial li-
birthweight and subsequent development of caries: A quid oral medication long-term. Caries Res 1996;30(1):
systematic review. J Dent Ed 2001;65(10):1017-23. 16-21.
7. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence 19. Bigeard L. The role of medication and sugars in pediatric
of obesity and trends in body mass index among US dental patients. Dent Clin North Am 2000;44(3):
children and adolescents, 1999–2010. JAMA 2012;307 443-56.
(5):483-90. 20. Foster H, Fitzgerald J. Dental disease in children with
8. U.S. Department of Health and Human Services, U.S. chronic illness. Arch Dis Child 2005;90(7):703-8.
Department of Agriculture. 2015–2020 Dietary Guide- 21. Lam HS, Chow CH, Poon WT, et al. Risk of vitamin
lines for Americans, 8th ed, Washington, D.C.: U.S. A toxicity from candylike chewable vitamin supplements
Department of Health and Human Services and U.S. for children. Pediatrics 2006;118(2):820-4.
Department of Agriculture; 2016. Available at: “https:// 22. Gidding SS, Dennison BA, Birch LL, et al. Dietary rec-
health.gov/dietaryguidelines/2015/guidelines/”. Accessed ommendations for children and adolescents: A guide for
November 25, 2016. (Archived by WebCite® at: “http: practitioners. Pediatrics 2006;117(2):544-59.
//www.webcitation.org/6siU5uUad”) 23. Wright R, Casamassimo PS. Assessing the attitudes and
9. World Health Organization. Guideline: Sugars intake for actions of pediatric dentists toward childhood obesity
adults and children. Geneva, Switzerland: World Health and sugar-sweetened beverages. J Pub Health Dent 2017;
Organization; 2015. Available at: “http://apps.who.int/iris 77(Suppl. 1):S79-S87.
/bitstream/10665/149782/1/9789241549028_eng.pdf?
ua=1”. Accessed March 21, 2017. (Archived by WebCite®
at: “http://www.webcitation.org/6p8TH1hvk”)

ORAL HEALTH POLICIES: SNACKS AND BEVERAGES IN SCHOOLS
Policy on Snacks and Beverages Sold in Schools

2017 snacks and beverages sold in schools. The Reference of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:
87-8.
Purpose There is growing concern that vending machine items with

The American Academy of Pediatric Dentistry (AAPD) limited nutritional value are competitive foods, resulting in
recognizes that targeted marketing and easy access to sweetened snack options that are considered to be of poor nutritional
foods and beverages (acidulated carbonated and noncarbon- quality.10-12 As teenage girls have increased their consumption
ated) by children and adolescents may increase the amount of soft drinks, their consumption of milk has decreased by
and frequency of their consumption which, in turn, may 40 percent, which may contribute to a decrease in bone den-
contribute to an increase in caries risk and a negative influence sity, subsequent increase in fractures, and future risk of osteo-
on overall nutrition and health. porosis. 13,14 Increased ingestion of sugar-sweetened drinks
also has been linked to the increased incidence of childhood
Methods obesity.15 Of all beverages, increasing soda consumption pre-
This document was developed by the Council on Clinical dicted the greatest increase of body mass index (BMI) and
Affairs and adopted in 2002. The last revision occurred in the lowest increase in calcium intake. 16 Carbonated soda
2009 and was reaffirmed in 2012. This revision is based upon consumption was negatively associated with vitamin A intake
a review of current dental and medical literature, including a in all age strata, calcium intake in children younger than 12
®
schools, vending machines, AND caries; fields: all; limits:
years, and magnesium intake in children aged 6 years and
older.17 Many soft drinks also contain significant amounts of
within the last 10 years, humans, English, clinical trials, and caffeine which, if consumed regularly, may lead to increased,
ages birth through 18. The update also included a review of even habitual, usage.18
the American Academy of Pediatrics’ (AAP) policy statement: In 2013, the USDA initiated smart snacks standards
Soft Drinks in Schools,1 the AAP’s policy statement: Snacks, prompting school districts to offer healthier food and beverages
Sweetened Beverages, Added Sugars and Schools,2 and the U.S. in vending machines, school stores, and à la carte cafeteria
Department of Agriculture (USDA) policies on school meals.3,4 lines.19 The final rules released by the USDA in July, 2016
Papers for review were chosen from the resultant lists and state that schools must continue to meet strong nutritional
from hand searches. Expert and/or consensus opinion by ex- guidelines for snacks/drinks sold to children, and they pre-
perienced researchers and clinicians also was considered. vent marketing of foods and drinks inconsistent with those
standards. 4 The USDA’s rules establish a national baseline
Background of these standards with the overall goal of improving health
Contemporary changes in beverage consumption patterns have and nutrition of our children.
the potential to increase dental caries rates in children. Vending
machines provide ready access to highly-refined carbohydrates, Policy statement
especially soft drinks* . Consumption of regular soda pop, The AAPD:
powdered beverages, and to a lesser extent 100 percent juice • Encourages collaboration with other dental and medical
has been associated with an increased caries risk.5 The acids organizations, governmental agencies, education offi-
present in carbonated beverages can have a greater deleterious cials, parent and consumer groups, and corporations
effect (i.e., erosion) on enamel than the acids generated by to increase public awareness of the adverse effects of
oral flora from the sugars present in sweetened drinks.6 Anal- frequent and/or inappropriate intake of sugar-sweetened
ysis of the third National Health and Nutrition Examination beverages and low nutrient dense snack foods on chil-
Survey (NHANES) III data 7 indicated that 13 percent of dren’s oral health and general health.
children aged two through 10 had diets high in consumption • Promotes educating and informing the public regarding
of carbonated soft drinks, and these children had a signifi- the importance of good nutritional habits as they pertain
cantly higher dental caries experience in the primary dentition to consumption of items available in vending machines.
than did children with other fluid consumption patterns.8
A significant increase in caries scores has been reported for
children who attended schools that had vending machines.9 ABBREVIATIONS
AAP: American Academy of Pediatrics. AAPD: American Academy
Pediatric Dentistry. USDA: U.S. Department of Agriculture.
For the purposes of this statement, the term soft drinks refers to such
* beverages as sodas, fruit juices, and sports drinks.

ORAL HEALTH POLICIES: SNACKS AND BEVERAGES IN SCHOOLS
• Encourages school officials and parent groups to consider 9. Maliderou M, Reeves S, Nobel C. The effect of social
the importance of maintaining healthy choices in vend- demographic factors, snack consumption, and vending
ing machines in schools and encourages the promotion machine use on oral health of children living in London.
of food and beverages of high nutritional value; bottled British Dent J 2006;201(7):441-4.
water and other more healthy choices should be avail- 10. U.S. Government Accountability Office. Report to Con-
able instead of soft drinks. gressional Requests: School Meal Programs Competitive
• Opposes any arrangements that may decrease access to Foods are Widely Available and Generate Substantial
healthy nutritional choices for children and adolescents Revenues for Schools. 2005. Available at: “http://www.
in schools. gao.gov/new.items/d05563.pdf ”. Accessed March 22,
References citation.org/6p9cOMgQF”)
®
2017. (Archived by WebCite at: “http://www.web
1. American Academy of Pediatrics Committee on School 11. Kakarala M, Keast DR, Hoerr S. Schoolchildren’s con-
Health. Policy statement: Soft drinks in schools. Pediatrics sumption of competitive foods and beverages, excluding
2004;113(1Pt+1):152-4. Reaffirmed December, 2012. à la carte. J Sch Health 2010;80(9):429-35.
2. American Academy of Pediatrics. Policy statement: 12. Pasch KE, Lytle LA, Samuelson AC, Farbakhsh K, Kubik
Snacks, sweetened beverages, added sugars, and schools. MY, Patnode CD. Are school vending machines loaded
Pediatrics 2015;135(3):D1-4. with calories and fat: An assessment of 106 middle and
3. U.S. Department of Agriculture Food and Nutrition high schools. J Sch Health 2011;81(4):212-8.
Service. Nutrition standards for school meals. Available 13. Wyshak G. Teenaged girls, carbonated beverage con-
at: “https://www.fns.usda.gov/school-meals/nutrition- sumption, and bone fractures. Arch Pediatr Adolesc Med
standards-school-meals”. Accessed June 30, 2017. 2000;154(6):610-3.
4. U.S. Department of Agriculture Food and Nutrition 14. Ludwig DS, Peterson KE, Gortmaker SL. Relation be-
Service. National school lunch program and school tween consumption of sugar-sweetened drinks and
breakfast program: Nutrition standards for all foods sold childhood obesity: A prospective, observational analysis.
in school as required by the Healthy, Hunger-free Kids Lancet 2001;357(9255):505-8.
Act of 2010. Final rule and interim final rule. 7 C.F.R. 15. Fox MK, Dodd AH Wilson A, Gleason PM. Association
Parts 210 and 220. Available at: “https://www.gpo. between school food environment and practices and
gov/fdsys/pkg/FR-2016-0729/pdf/2016-17227.pdf ”. body mass index of US public school children. J Am Diet
“http://www.webcitation.org/6p9bqqE15”)
® Assoc 2009;109(2 Suppl):S108-17.
16. Striegel-Moore RH, Thompson D, Affenito SG, et al.
5. Marshall TA, Levy SM, Broffitt B, et al. Dental caries Correlates of beverage intake in adolescent girls: The
and beverage consumption in young children. Pediatr national heart, lung, and blood institute growth and
2003;112(3 Pt 1):e184-91. health study. J Pediatr 2006;148(2):183-7.
6. Joint Report of the American Dental Association Council 17. Ballew C, Kuester S, Gillespie C. Beverage choices affect
on Access, Prevention, and Interprofessional Relations adequacy of children’s nutrient intakes. Arch Pediatr
and Council on Scientific Affairs to the House of Dele- Adolesc Med 2000;154(11):1148-52.
gates. Response to Resolution 73H-2000. Chicago, Ill.: 18. Majewski R. Dental caries in adolescents associated with
American Dental Association; 2001. caffeinated carbonated beverages. Pediatr Dent 2001;23
7. Centers for Disease Control and Prevention, National (3):198-203.
Center for Health Statistics. National Health and Ex- 19. U.S. Department of Agriculture Food and Nutrition
amination Survey Data. (NHANES III) Hyattsville, Md.: Service. National School Lunch Program and School
U.S. Department of Health and Human Services, Center Breakfast Program: Nutrition Standards for All Foods
for Disease Control; 2012. Available at: “https://www. Sold in School as Required by the Healthy, Hunger-Free
cdc.gov/nchs/nhanes/nhanes3.htm”. Accessed March Kids Act of 2010. Proposed Rule. 7 C.F.R. Parts 210 and
citation.org/6p9cTnaGZ”)
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22, 2017. (Archived by WebCite at: “http://www.web 220. Available at: “http://fns.usda.gov/sites/default/files/
fdpir/02.13.13-QTC-Nutrition-Standards.pdf ”. Accessed
8. Sohn W, Burt BA, Sowers MR. Carbonated soft drinks
and dental caries in the primary dentition. J Dent Res
®
March 22, 2017. (Archived by WebCite at: “http://
www.webcitation.org/6tbNuFhAL”)
2006;85(3):262-6.

ORAL HEALTH POLICIES: TOBACCO USE
Policy on Tobacco Use

2020 tobacco use. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
Purpose Youth use of tobacco

The American Academy of Pediatric Dentistry (AAPD), in The CDC has conducted a National Youth Tobacco Survey
order to reduce pain, disability, and death caused by nicotine (NYTS) for the years 1999, 2000, 2002, 2004, 2006, 2009,
addiction, recommends routine screening for tobacco use, 2011, and 2012 through 2019 as part of the Healthy People
treating tobacco dependence, preventing tobacco use among 2010 and 2020 objectives on tobacco use.5 The NYTS also
children and adolescents, and educating the public on the serves as a baseline for comparing progress toward meeting
enormous health and societal costs of tobacco. select Healthy People 2020 goals for reducing tobacco use
among youth, especially in adolescents in grades 6-12. Data
Methods show that:
This policy was developed by the Council on Clinical Affairs • Smoking and smokeless tobacco use are initiated and
and adopted in 2000.1 This document is an update of the established primarily during adolescence.4 Nearly nine
previous version, revised in 2015.2 This policy revision is based out of 10 smokers started smoking by age 18, and 98
upon a review of current dental, medical, and public health percent started by age 26.6
literature related to tobacco use which included a search of • Each day in the U.S., about 2000 people younger than
®
the PubMed /MEDLINE database using the terms: child and
adolescent tobacco use, smokeless tobacco and oral disease,
18 years of age smoke their first cigarette, and more than
300 youth under 18 years of age become daily cigarette
adolescent pregnancy and tobacco, secondhand smoke, and smokers.7
caries and smoking; fields: all; limits: within the last 10 years, • If smoking persists at the current rate among youth in
humans, English, clinical studies, meta-analysis, systematic this country, 5.6 million of today’s population younger
reviews, birth through age 18. The search returned 525 articles than 18 years of age are projected to die prematurely
that matched the criteria. The articles were evaluated by title from a smoking-related illness.4 This represents about
and/or abstract. Forty-nine articles were chosen from this one in every 13 Americans aged 17 years or younger
method and from references within selected articles. Websites alive today.4
for the American Lung Association, American Cancer Society, • In 2017, 5.6 percent of middle school and 19.6 percent
Centers for Disease Control and Prevention (CDC), Environ- of high school students currently used tobacco products,
mental Protection Agency, Campaign for Tobacco Free Kids, including cigarettes, cigars, smokeless tobacco, pipe
and U.S. Department of Health and Human Services also tobacco, bidis (unfiltered cigarettes from India), and
were reviewed. electronic cigarettes.8
• From 2011 to 2019, current use of smokeless tobacco
Background decreased among middle and high school students.9
Tobacco is a risk factor for six of the eight leading causes of Nearly two of every 100 middle school students (1.8
deaths in the world, and it kills nearly more than eight million percent) reported in 2019 that they had used smokeless
people a year.3 Tobacco use is considered one of the largest tobacco in the last 30 days, a decrease from 2.2 percent
public health threats the world has ever faced.3,4 More than in 2011.9 Nearly five out of every 100 high school stu-
1.2 million deaths are the result of non-smokers being exposed dents (5.9 percent) reported in 2019 that they used
to second-hand smoke.3 Up to half of current users eventually smokeless tobacco in the last 30 days, a decrease from
will die of a tobacco-related disease.3 In the U.S., the Surgeon 7.9 percent in 2011.9 Smokeless tobacco use remains a
General’s report states that smoking is the single greatest avoid- mostly male behavior,9 being seen in 7.5 percent of male
able cause of death.4 According to the report, “The epidemic high school students and 1.8 percent of females.9
of smoking-caused disease in the twentieth century ranks
amongst the greatest public catastrophes of the century, while
the decline of smoking consequent to tobacco control is one ABBREVIATIONS
of public health’s greatest successes.”4 AAPD: American Academy Pediatric Dentistry. CDC: Centers for
Disease Control and Prevention. ETS: Environmental tobacco
smoke. NYTS: National Youth Tobacco Survey.

Reports show that most people who use cigarettes begin children inhabit these low-lying contaminated areas and
smoking as a teen.4,6 Aggressive marketing of tobacco prod- because the dust ingestion rate in infants is more than twice
ucts by manufacturers, 6,10-13 smoking by parents, 10,13,14 peer that of an adult, they are even more susceptible to third-
influence,6,10,13 a functional belief in the benefits and normalcy hand smoke. Studies have shown that these children have
of tobacco,10,13,15 availability and price of tobacco products,10,13 associated cognitive deficits in addition to the other associated
low socioeconomic status, 10 low academic achievement, 6,10 risks of secondhand smoke exposure.34
lower self-image, 10 and a lack of behavioral skills to resist Tobacco use can result in oral disease. Oral cancer,3,4,19
tobacco offers10 all contribute to the initiation of tobacco use periodontitis,4,23,37-41 compromised wound healing, a reduction
during childhood and adolescence. Teens who use tobacco are in the ability to smell and taste23, smoker’s palate (red inflam-
more likely to use alcohol and other drugs10 and engage in mation turning to harder white thickened tissues), and
high risk sexual behaviors.16,17 melanosis (dark pigmenting of the oral tissues), coated tongue,
If youth can be discouraged from starting smoking, it is less staining of teeth23 and restorations23,41, implant failure4, and
likely that they will start smoking as an adult. The 2012 Sur- leukoplakia41,42 are all seen in tobacco users.42,43 Use of smoke-
geon General’s Report concluded that there is a large evidence less tobacco is a risk factor for oral cancer, leukoplakia, and
base for effective strategies to prevent and minimize tobacco erythroplakia, loss of periodontal support, and staining of
use by children and young adults by decreasing the number teeth and composite restorations.41
of children who initiate tobacco use and by increasing the The monetary costs of this addiction and resultant morbid-
current users who quit.6 Oral health professionals can have ity and mortality are staggering. Annually, cigarette smoking
success with tobacco cessation by counseling patients during costs the U.S. $300 billion, based on lost productivity (more
the oral examination component of dental visits.18 than $156 billion) and health care expenditures (nearly
$170 billion).44 Lost productivity due to exposure to second-
Consequences of tobacco use hand smoke is about $5.6 billion annually.44 Contrast this
Smoking increases the risk for: coronary heart disease by 2-4 with tobacco industry expenditures on advertising and political
times, stroke by 2-4 times, men developing lung cancer by promotional expenses of $ 8.4 billion in 2018 in the U.S.
25 times, and women developing lung cancer 25.7 times.19 alone.44
Smoking causes diminished overall health, increased absen- Current trends indicate that tobacco use will cause more
teeism from work, and increased health care utilization and than eight million deaths a year by 2030.3 It is incumbent on
cost.6,20 Other catastrophic health outcomes are cardiovascular the healthcare community to reduce the burden of tobacco-
disease; reproductive effects; pulmonary disease; leukemia; related morbidity and mortality by supporting preventive
cataracts; and cancers of the cervix, kidney, pancreas, stomach, measures, educating the public about the risks of tobacco,
lung, larynx, bladder, oropharynx, and esophagus.19 and screening for tobacco use and nicotine dependence.
Environmental tobacco smoke ([ETS]; secondhand or
passive smoke) imposes significant risks as well. Secondhand Policy statement
exposure results in the death of 41,000 nonsmoking adults The AAPD opposes the use of all forms of tobacco including
and 400 infants each year.21 The Surgeon General reported a cigarettes, pipes, cigars, bidis, kreteks, and smokeless tobacco
25 to 30 percent increased risk for coronary heart disease for and alternative nicotine delivery systems, such as tobacco
non-smokers exposed to secondhand smoke and a 20 to 30 lozenges, nicotine water, nicotine lollipops, or heated tobacco-
percent increased risk for lung cancer for those living with a cigarette substitutes (electronic cigarettes). The AAPD supports
smoker.22 Infants and children who are exposed to smoke are national, state, and local legislation that eliminates tobacco
at risk for sudden infant death syndrome (SIDS) 3,19,22,23, advertising and promotions that appeal to or influence children,
acute respiratory infections23, middle ear infections23, bron- adolescents, or special groups. The AAPD supports prevention
chitis23, pneumonia23, asthma23-25, allergies26,27, and infections efforts through merchant education and enforcement of state
during infancy.28 In addition, caries in the primary dentition and local laws prohibiting tobacco sales to minors. As ETS is
is related to secondhand smoke exposure.29-31 Enamel hypo- a known human carcinogen and there is no evidence to date
plasia in both the primary and permanent dentition may of a safe exposure level to ETS,23 the AAPD also supports the
be related to secondhand cigarette smoke exposure during enactment and enforcement of state and local clean indoor air
childhood. 32 Prenatal exposure to secondhand smoke has and/or smoke-free policies or ordinances prohibiting smoking
been associated with cognitive deficits 23 (e.g., reasoning in public places.
abilities) and deficits in reading, mathematics, and visuospatial Furthermore, the AAPD encourages oral health profes-
relationships.33 sionals to:
Thirdhand smoke refers to the particulate residual toxins • determine and document tobacco use by patients and the
that are deposited in layers all over the home after a cigarette smoking status of their parents, guardians, and caregivers.
has been extinguished. 34 These volatile compounds are • promote and establish policies that ensure dental offices,
deposited and emit gas into the air over months. 35,36 Since clinics, and/or health care facilities, including property
grounds, are tobacco free.

• support tobacco-free school laws and policies. 5. U.S. Department of Health and Human Services. Healthy
• serve as role models by not using tobacco and urging people 2020: Tobacco use and healthy people 2020
staff members who use tobacco to stop. objectives-Tobacco priority area. Washington, D.C., 2014
• routinely examine patients for oral signs of and changes Available at: “https://www.healthypeople.gov/2020/
associated with tobacco use. topics-objectives/topic/tobacco-use”. Accessed August
• educate patients, parents, and guardians on the serious 7, 2020.
health consequences of tobacco use and exposure to ETS 6. U.S. Department of Health and Human Services. Pre-
in the home. venting Tobacco Use Among Youth and Young Adults:
• provide both prevention and cessation services using A Report of the Surgeon General. Atlanta, Ga.: U.S.
evidence-based interventions identified as best practice Department of Health and Human Services, Centers for
for treating tobacco use and nicotine addiction. Disease Control and Prevention, Office on Smoking and
• work to ensure all third-party payors include best practice Health; 2012. Available at: “https://www.ncbi.nlm.nih.
tobacco cessation counseling and pharmacotherapeutic gov/books/NBK99237/”. Accessed August 7, 2020.
treatments as benefits in health packages. 7. Centers for Disease Control and Prevention. Smoking
• work with school boards to increase tobacco-free envi- and Tobacco Use: Fast Facts. Available at: “https://www.
ronments for all school facilities, property, vehicles, and cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.
school events. htm#beginning”. Accessed August 7, 2020.
• work on the national level and within their state and 8. Wang, TW, Gentzke A, Sharapova S, Cullen KA, Ambrose
community to organize and support anti-tobacco cam- BK, Jamal A. Tobacco product use among middle and
paigns and to prevent the initiation of tobacco use among high school students-United States, 2011-2017. MMWR
children and adolescents, eliminate cigarette sales from Morb Mortal Wkly Rep 2018;67:629-33. Available at:
vending machines, and increase excise tax on tobacco “https://www.ncbi.nlm.nih.gov/pmc/articles/PMC
products to reduce demand. 5991815/”. Accessed November 11, 2020.
• work with legislators, community leaders, and health care 9. Centers for Disease Control and Prevention. Youth and
organizations to ban tobacco advertising, promotion, and Tobacco Use. Available at: “https://www.cdc.gov/tobacco
sponsorships. /data_statistics/fact_sheets/youth_data/tobacco_use/
• organize and support efforts to pass national, state, and index.htm”. Accessed November 11, 2020.
local legislation prohibiting smoking in businesses such 10. Elders MJ, Perry CL, Eriksen MP, Giovino GA. The
as day-care centers where children routinely visit and report of the Surgeon General: Preventing tobacco use
other establishments where adolescents frequently are among young people. Am J Public Health 1994;84(4):
employed. 543-7. Available at: “https://www.ncbi.nlm.nih.gov/pmc/
• establish and support education/training activities and articles/PMC1614776/”. Accessed August 7, 2020.
prevention/cessation services throughout the community. 11. Centers for Disease Control and Prevention. Cigarette
• recognize the U.S. Public Health Service Clinical brand preference among middle and high school students
Practice Guideline Treating Tobacco Use and Dependence45 who are established smokers – United States, 2004 and
as a valuable resource. 2006. MMWR Morb Mortal Wkly Rep 2009;58(5):
112-5.
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Pediatr Dent 2015;37(special issue):61-5. 13. American Lung Association. Why kids start smoking.
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4. U.S. Department of Health and Human Services. The 14. Gilman SE, Rende R, Boergers J, et al. Parental smoking
Health Consequences of Smoking – 50 Years of Progress: and adolescent smoking initiation: An intergenerational
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Disease Control and Prevention, National Center of 15. Song AV, Morrell HE, Cornell JL, et al. Perceptions of
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Accessed August 7, 2020. Environ Health Perspect 2005;113(1):98-103.
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analysis. J Asthma 2008;45(7):607-10. quences of smokeless tobacco use. Indian J Med Res
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August 7, 2020.

ORAL HEALTH POLICIES: E–CIGARETTES
Policy on Electronic Nicotine Delivery Systems (ENDS)

2020 electronic nicotine delivery systems (ENDS). The Reference Manual
Purpose products for adult smoking cessation.13 E-cigarette solutions

The American Academy of Pediatric Dentistry (AAPD) come in a variety of flavors and nicotine concentrations.7,13
recognizes the increased use of electronic cigarettes (e-cigarettes) The U.S. Preventive Services Task Force found that two of
among children and adolescents. This policy intends to educate the strongest factors associated with initiation of smoking by
professionals, parents, and patients about electronic nicotine children are parental smoking and parental nicotine depen-
delivery systems (ENDS). Nicotine is highly addictive and has dence.14 Studies have shown that exposure to nicotine has a
negative effects on brain development from the prenatal period deleterious effect on the brain of children and adolescents. 1,15
into adolescence.1 In order to reduce health risks caused by E-cigarette use is rising among adolescents at an alarming rate,
nicotine addiction, the AAPD supports routine screening for and recent studies show that e-cigarette use among teens has
tobacco use, treating tobacco dependence, preventing tobacco surpassed tobacco cigarette use.5,16 In 2019, 27 percent of high
use among children and adolescents, and educating the public school students and 10.5 percent of middle school students
on the health and societal costs of use of e-cigarettes/ENDS. reported current e-cigarette usage. 17 Since 90 percent of all
adult tobacco smokers reported starting smoking as a teen-
Methods ager,18 and almost 38 percent of habitual e-cigarette users never
This policy was developed by the Council of Clinical Affairs smoked tobacco products,19,20 the potential for increased use
and adopted in 2015.2 This revision is based on a review of of e-cigarettes is a public concern. E-cigarettes may serve as an
dental and medical literature and sources of recognized profes- entry point for use of nicotine, an addictive drug.16 Adolescents
sional expertise and stature, including both the academic and and young adults who used e-cigarettes were found to be 3.5
practicing health care communities, related to ENDS use by times more likely to report using traditional cigarettes21 despite
the pediatric patient. In addition, a search of the PubMed /
MEDLINE database was performed using the terms: e-
® having lower behavioral and social risk factors than those who
smoked conventional cigarettes22.
cigarette use in children, e-cigarette use in adolescents, ENDS Due to lack of regulation in e-cigarette marketing, the
use in children, ENDS use in adolescents, nicotine effects on sleek designs of the new products, and the appealing flavors,
health; fields: all; limits: within the last 10 years, humans, children who are impressionable and model the behavior of
English, birth through age 18. Papers for review were chosen adults are at risk from marketing that normally is banned for
from this search and from references within selected articles. tobacco containing products.3 ENDS solutions are available in
When data did not appear sufficient or were inconclusive, a number of enticing and appealing flavors, including fruit,
policies were based upon expert and/or consensus opinion by candy, and dessert flavors such as Belgian waffle and choco-
late.23 Although they have not been banned for e-cigarettes,
experienced researchers and clinicians.
these flavors have been banned in tobacco cigarettes due to
their appeal to children, adolescents, and first time users.24 In
Background
2016, 78.2 percent of middle and high school students were
E-cigarettes, also called ENDS, are handheld devices that
exposed to ENDS advertising from at least one source.3
produce an aerosol from a solution typically containing nico-
In 2016, the Family Smoking Prevention and Tobacco
tine, flavoring chemicals, and other additives to be inhaled by
Control Act25 was expanded to include regulation of ENDS.
the user.3-5 The act of using an e-cigarette/ENDS commonly is
Among the regulations set forth are a requirement that manu-
called vaping due to the vapors that are inhaled and exhaled;
facturers submit an application for review to determine the
however, the emission from an ENDS is most accurately clas-
safety of their products by 2020.26 Previously, manufacturers
sified as an aerosol to which non-users also can be exposed.3,4
E-cigarettes are marketed6 as a less harmful alternative for
tobacco smokers to consume nicotine.7 They also are used as an ABBREVIATIONS
aid to stop smoking tobacco-containing products,8,9 although AAPD: American Academy Pediatric Dentistry. CBD: Cannabinoid.
studies relating to the effectiveness of e-cigarettes as a smoking E-cigarettes: Electronic cigarettes. ENDS: Electronic nicotine
cessation tool have had mixed results, and the use of e-cigarettes delivery systems. EVALI: E-cigarette or vaping product use lung
for tobacco cessation is not clearly supported by scientific evi- illness. FDA: U.S. Food and Drug Administration. mg: Milligram.
mL: Milliliter. THC: Tetrahydrocannabinol.
dence.10-12 There currently are no federally-approved e-cigarette

were not required to disclose their ingredients.27,28 The U.S. • supports the inclusion of e-cigarettes in the non-smoking
Food and Drug Administration (FDA)’s “deeming rule” also laws in restaurants and public places.
bans the sale of ENDS to anyone under 18 years old, requires • supports national, state, and local legislation that bans
producers to cease giving free samples, and requires warning the sale of e-cigarettes to children and eliminates adver-
labels stating that nicotine is addictive.26 Unfortunately, the tising and/or promotion of e-cigarettes that appeals to
regulation does not address flavors or nicotine strength and or influences children, adolescents, or special groups.
does not appropriately restrict the advertising of ENDS. • opposes the use of all forms of unregulated nicotine
The base solution contains propylene glycol which can delivery systems, such as tobacco lozenges, nicotine
cause eye, throat, and airway irritation and with long term water, nicotine lollipops, and heated tobacco cigarette
exposure can cause asthma in children.29 A five milliter (mL) substitutes.
vial of e-cigarette refill solution can contain a nicotine concen-
tration of 20 milligrams (mg)/mL or 100 mg per vial.30 The References
known lethal dose of nicotine has been estimated to be about 1. Dwyer J, McQuown S, Leslie F. The dynamic effects of
10 mg in children and between 30 and 60 mg in adults.30 nicotine on the developing brain. Pharmacol Ther 2009;
Recently, there has been a national outbreak of lung-associated 122(2):125-39.
injuries and deaths reported with e-cigarette use and vaping.31 2. American Academy of Pediatrics Dentistry. Policy on
The liquid can contain nicotine, tetrahydrocannabinol (THC) e-cigarettes. Pediatr Dent 2015;37(special issue):66-8.
and cannabinoid (CBD) oils, and other substances and addi- 3. Jenssen BP, Walley SC, AAP Section on Tobacco Control.
tives.31 The current chemical exposure causing lung injuries E-cigarettes and similar devices. Pediatrics 2019;143(2):
remains unknown; however, recent analyses of bronchoalveolar e20183652. Available at: “https://pediatrics.aappublica
lavage fluid samples of those affected has shown vitamin E tions.org/content/pediatrics/143/2/e20183652.full.pdf ”.
acetate to be associated with e-cigarette or vaping product use Accessed July 7, 2020.
lung illness (EVALI).31 THC is present in most of the samples 4. Sutfin EL, McCoy TP, Morrell HER, Hoeppner BB,
tested by FDA.31 No one compound or ingredient has emerged Wolfson M. Electronic cigarette use by college students.
to cause the illness to date, and many different product sources Drug and Alcohol Depend 2013;131(3):214-21.
are being investigated at this time.31 That the components of 5. U.S. Department of Health and Human Services E-
ENDS are not entirely disclosed and can vary according to Cigarette Use Among Youth and Young Adults. A Report
manufacturer poses pressing concerns.31 of the Surgeon General. Atlanta, Ga.: U.S. Department of
As e-cigarettes have become popular as a substitute for Health and Human Services, Centers for Disease Control
tobacco smoking due to indoor smoking restrictions,32 the and Prevention, National Center for Chronic Disease
effect of the exhaled vapors is also a concern. A number of Prevention and Health Promotion, Office on Smoking
toxic and potentially carcinogenic compounds have been and Health, 2016. Available at: “https://e-cigarettes.
found in the vapors of e-cigarettes.33,34 Unrestricted access to surgeongeneral.gov/documents/2016_SGR_Full_Report
smoking of e-cigarettes not only poses health risks to the user, _non-508.pdf ”. Accessed July 7, 2020
but also may pose health risks to people nearby due to 6. Grana R, Ling P. Smoking revolution: A content analysis
secondhand exposure of the vapors. 31 One study showed of electronic cigarette retail websites. Am J Prev Med
a similar effect on serum levels of cotinine (a biomarker for 2014;46(4):395-403.
exposure to tobacco smoke) with an one-hour exposure to 7. Taylor N, Choi K, Forster J. Snus use and smoking
both secondhand cigarette smoke and e-cigarette vapors.35 behaviors: Preliminary findings from a prospective cohort
study among U.S. Midwest young adults. Am J Public
Policy statement Health 2015;105(4):683-5.
The AAPD: 8. Ayers J, Ribisl K, Brownstein J. Tracking the rise in
• recognizes the potential hazards associated with the popularity of electronic nicotine delivery systems (elec-
use of electronic nicotine delivery systems. tronic cigarettes) using search query surveillance. Am J
• encourages all members to educate patients, parents, Prev Med 2011;40(4):448-53.
and guardians on the health consequences of e-cigarettes 9. Dawkins L, Turner J, Roberts A, Soar K. ‘Vaping’ profiles
and other forms of nicotine delivery systems. and preferences: An online survey of electronic cigarette
• encourages the enactment of FDA regulations on e- users. Addiction 2013;108(6):1115-25.
cigarette/ENDS distribution including, but not limited 10. Bullen C, Howe C, Laugesen M, et al. Electronic cig-
to, prohibiting sales to children under 21, banning the arettes for smoking cessation: A randomized controlled
child-friendly flavoring of e-cigarettes, and limiting the trial. Lancet 2013;382(9905):1629-37.
use for smoking cessation purposes.
• supports more studies being done on the effects of the
secondhand vapors and the compounds produced from References continued on the next page.
e-cigarettes.

11. Ghosh A, Coakley RC, Mascenik T, et al. Chronic e- 2017;171(8):788-97. [published correction appears in
cigarette exposure alters the human bronchial epithelial JAMA Pediatr 2018;172(1):98].
proteome. Am J Respir Crit Care Med 2018;198(1):67- 22. Wills TA, Sargent JD, Gibbons FX, Pagano I, Schweitzer
76. Available at: “https://www.atsjournals.org/doi/10.11 R. E-cigarette use is differentially related to smoking onset
64/rccm.201710-2033OC”. Accessed October 3, 2020. among lower risk adolescents. Tob Control 2016;26(5):
12. National Academies of Sciences, Engineering, and Med- 534-9.
icine. Public Health Consequences of E-Cigarettes. 23. Walley SC, Jenssen BP, Section on Tobacco Control.
Washington, D.C.: The National Academies Press; 2018. Electronic nicotine delivery systems. Pediatrics 2015;
Available at: “https://www.ncbi.nlm.nih.gov/books/ 136(5):1018-26. Available at: “https://pediatrics.aap
NBK507171/pdf/Bookshelf_NBK507171.pdf ”. Accessed publications.org/content/136/5/1018”. Accessed October
October 5, 2020. 31, 2020.
13. Walley SC, Wilson KM, Winickoff JP, Groner J. A public 24. U.S. Department of Health and Human Services. Pre-
health crisis: Electronic cigarettes, vape, and JUUL. venting Tobacco Use Among Youth and Young Adults:
Pediatrics 2019;143(6):e20182741. A Report of the Surgeon General. Atlanta, Ga.: U.S.
14. Moyer VA, U.S. Preventive Task Force. Primary care Department of Health and Human Services, Centers for
interventions to prevent tobacco use in children and Disease Prevention and Control, National Center for
adolescents: U.S. Preventive Task Force recommendation Chronic Disease Prevention and Health Promotion,
statement. Ann Intern Med 2013;159(8):552-7. Office on Smoking and Health; 2012. Available at:
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during adolescence alters the rules for prefrontal cortical Accessed October 3, 2020.
synaptic plasticity during adulthood. Front Synaptic 25. U.S. Congress. Family smoking prevention and tobacco
Neurosci 2012;4:3. Available at: “https://www.frontiers control act. June 22, 2009. Available at: “https://www.
in.org/articles/10.3389/fnsyn.2012.00003/full”. Accessed govinfo.gov/content/pkg/PLAW-111publ31/pdf/PLAW
July 7, 2020. -111publ31.pdf ”. Accessed July 7, 2020.
16. Johnston LD, O’Malley PM, Miech RA, et al. Monitoring 26. Sharpless N. FDA Voices: How FDA is regulating e-
the future national results on adolescent drug use, 1975- cigarettes. September 10, 2019. U.S. Food and Drug
2015. Overview, key findings on adolescent drug use. Administration. Available at: “https://www.fda.gov/news
Ann Arbor, Mich.: Institute for Social Research, The -events/fda-voices/how-fda-regulating-e-cigarettes”.
University of Michigan; 2016. Available at: “https://files. Accessed October 5, 2020.
eric.ed.gov/fulltext/ED578539.pdf ”. Accessed October 27. Farsalinos KE, Spyrou A, Tsimopoulou K, Stefopoulos
5, 2020. C, Romagna G, Voudris V. Nicotine absorption from
17. Cullen KA, Gentzke AS, Sawdey MD, et al. E-cigarette electronic cigarette use: Comparison between first and
use among youth in the United States, 2019. J Am Med new-generation devices. Sci Rep 2014;4:4133. Available
Assoc 2019;322(21):2095-103. Available at: “https:// at: “https://doi.org/10.1038/srep04133”. Accessed July
www.ncbi.nlm.nih.gov/pmc/articles/PMC6865299/”. 7, 2020.
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18. U.S. Department of Health and Human Services. Prevent- delivery systems and public health: The rise of the
ing Tobacco Use Among Youth and Young Adults, Fact “e-cigarette”. Am J Public Health 2010;100(12):2340-2.
Sheet, U.S. Department of Health and Human Services, 29. Choi H, Schmidbauer N, Spengler J, Bornehag C. Sources
Washington, D.C. Available at: “https://www.hhs.gov/ of propylene glycol and glycol ethers in air at home. Int
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October 5, 2020. M, Roll M. Variable and potentially fatal amounts of
19. Kong G, Morean ME, Cavallo DA, Camenga DR, nicotine in ENDS nicotine solutions. Tob Control 2014;
Krishnan-Sarin S. Reasons for electronic cigarette 23(1):77-8.
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and young adults. Nicotine Tob Res 2015;17(7):847-54. and tobacco use: Outbreak of lung injury associated with
20. Wills T, Knight R, Williams R, Pagano I, Sargent J. Risk the use of e-cigarette, or vaping, products. February
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direct.com/science/article/pii/S1438463914000972?via
%3Dihub”. Accessed October 5, 2020.

ORAL HEALTH POLICIES: SUBSTANCE ABUSE IN ADOLESCENTS
Policy on Substance Abuse in Adolescent Patients

2016 substance abuse in adolescents patients. The Reference Manual of
Dentistry; 2020:98-101.
Purpose physiological and cognitive consequences, that is the

The American Academy of Pediatric Dentistry (AAPD) result of a cessation of, or reduction in, heavy and prolonged
recognizes that substance abuse in adolescents is a significant substance use”.5
health, social, and familial issue in the United States. The
increasing prevalence of substance abuse among adolescents Background
obligates dental personnel to identify behaviors characteristic Many physical, social, and behavioral changes occur during
of active use, recognize clinical signs and symptoms of the adolescent years. The developing adolescent may encounter
active use or withdrawal, modify dental treatment accordingly, difficulties and pressures without effective coping skills or
and facilitate referral to medical providers or behavioral maturity. Unfortunately, some teenagers do not have familial,
addiction specialists. This policy addresses the harmful effects peer, or other support systems to provide help and guidance
of alcohol and drug abuse in the adolescent and the dental in adjusting to changes or with decision making. As a result,
provider’s role in recognition, initiation of appropriate they may turn to alcohol or drugs to seek comfort and reduce
interventions, and referrals. the stresses associated with this erratic time in their lives.6
Substances abused by adolescents include alcohol, inhalants,
Methods opiates, amphetamines, cocaine, marijuana, barbiturates, ben-
This policy was developed by the Council on Clinical Affairs, zodiazepines, hallucinogens, and anabolic steroids.7,8 In a 2014
and is based upon a review of current dental and medical survey of eighth, tenth, and twelfth grade students, trends
®
literature, including a literature review through the PubMed /
MEDLINE database using the terms: adolescent substance
revealed alcohol use at 9.0, 23.5, and 37.5 percent respectively
in the previous 30 days.9 Prevalence of having been drunk in
abuse, substance use in adolescents, alcohol use in adolescents, the past 30 days was reported at 2.7, 11.2, and 23.5 percent.9
illicit drug and alcohol use in teenagers, adolescent alcohol Use of any illicit drug was reported to be 8.3 percent for
and/or drug abuse, prescription drug use/abuse in teenagers, eighth graders, 18.5 percent for tenth graders, and 23.7 percent
and inhalant use/abuse in teenagers; fields: all; limits: within for twelfth graders.9 Another recent survey found more than
the last 10 years, humans, English, birth through age 18. The 2.3 million youth aged 12-17 years were current users (i.e.,
authors agreed upon inclusion of 24 articles that matched in the past 30 days) of illicit drugs, equivalent to 9.4 percent
these criteria. Papers for review were chosen from this list of adolescents.10 Current alcohol use was higher, reported at
and from the references within selected articles. Websites and 11.5 percent, corresponding to 2.9 million adolescents, with
documents from healthcare and public policy organizations, as binge drinking shown to occur in 6.1 percent.10 Among the
well as governmental agencies, were reviewed. same age group, current marijuana use was at 7.4 percent
(approximately 1.8 million adolescents). Abuse of prescription
Definitions drugs (i.e., analgesics, stimulants, anxiolytics, sedatives) for
Binge or heavy episodic drinking: consuming “more than non-medical purposes was reported by 2.6 percent of adoles-
five (alcoholic) drinks per drinking occasion”.1 cents.10 SUD was found to occur in five percent of
Substance abuse: a “maladaptive pattern of substance use adolescents, while alcohol use disorders were diagnosed in 2.7
manifested by recurrent and significant adverse consequences percent of adolescents.12 Recurrent use of drugs or alcohol
related to the repeated use of substances;”2 individual use of causes significant clinical and functional impairment such as
illicit (illegal) drugs or use of legal drugs inappropriately; health issues, disability, and failure to fulfill important respon-
repeated use of alcohol or drugs to produce pleasure, reduce sibilities at work, school, or home.11
stress, or alter or avoid reality.3 There is high probability that dental personnel will detect
Substance use disorder (SUD): “a cluster of cognitive, be- signs of possible substance abuse in their adolescent patient
havioral, and physiological symptoms indicating that the
individual continues using the substance despite significant
substance-related problems”.4 ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. SUD: Substance
Withdrawal syndrome: “the development of a substance-specific use disorder.
maladaptive behavioral change, usually with uncomfortable

population. Staff should be attentive to similar signs displayed risks of use or abuse of alcohol or other drugs, strong encour-
by the parent. Clinical presentations of substance use may agement for avoiding drugs and alcohol, motivational
include odor of alcohol on breath, odor of marijuana on interviewing,19 and initiating referrals for assessment and
clothing, impaired behavior, slurred speech, staggering gait, treatment by other health care providers.6-8,17,18 Although the
visual hallucinations, disorientation, rhinitis, scratching, phys- dental practitioner may grant patient confidentiality, he must
ical injuries including lacerations, needle marks, cellulitis, abide by state laws when treating minors.8 Involvement of
diaphoresis, tachycardia, sensory impairment, and pupillary the parent and other authorities is imperative when substance
dilation or constriction.8,12 Cognitive and behavioral manifes- abuse places the adolescent patient or others in a high-risk or
tations may present as mood changes or emotional instability, life-threatening situation.8,20 In such circumstances, the
loud obnoxious behavior, laughing at nothing, withdrawn/ patient should receive notification when disclosure of confi-
depressed affect, lack of communication/silence, hostility/ dential information will occur and be provided an opportunity
anger/uncooperative behavior, inability to speak intelligibly or to join the conversation.20
to focus, rapid-fire speech, hyperactivity, and unusually elated When providing treatment to a patient suspected of sub-
mood.12,13 Perioral and oral signs may include sores around the stance use, the dentist may need to modify sedation procedures,
mouth, continual wetting or licking of lips, clenched teeth, administration of local anesthetics, and prescribing practices.
bruxism, trismus, enamel chips or coronal fractures, neglected/ Administration of nitrous oxide or anxiolytic or sedative
poor oral hygiene, multiple cervical carious lesions, gingivitis, medications to an adolescent who is actively using or has a
gingival ulceration, periodontitis, pale mucosa, leukoplakia, current history of substance abuse can lead to unfavorable drug
and intraoral burns.8,12,14 Adolescents experiencing withdrawal interactions, over-sedation, or respiratory depression.8,17 Use
syndrome may demonstrate behaviors such as altered mental of these agents during remission/recovery from substance
status, agitation, irritability, restlessness, increased anxiety or abuse can predispose a patient to relapse.2,6,8 Dentists should
panic, and inattentiveness.5,8 Clinical signs and reported use local anesthetics containing vasoconstrictors judiciously
symptoms of substance withdrawal include rhinorrhea, tachy- in adolescent patients who abuse stimulant medications such
cardia, elevated temperature, yawning, tremors, hallucinations, as methylphenidate, amphetamine and dextroamphetamine,
and seizures.5,8 methamphetamine, and cocaine. Drug interactions between
Adolescent substance abuse frequently co-occurs with vasoconstrictors and stimulants can cause tachycardia, hyper-
mental disorders.2,4,6-8 SUD often coexists with psychiatric tension or hypotension, palpitations, hyperthermia, cardiac
conditions such as depression, anxiety disorders, attention- dysrhythmias, myocardial infarction, and cerebrovascular
deficit hyperactivity disorder, oppositional defiant disorder, accidents.8,21-23 Dentists should be knowledgeable of the various
conduct disorder, bipolar disorder, post-traumatic stress dis- SUDs (e.g., alcohol, opiate, benzodiazepine) when recom-
order, bulimia nervosa, social phobia, and schizophrenia.2,3,7,15 mending or prescribing medications. When pain management
Substance use may induce the deterioration, emergence, or is necessary, an adolescent with an opioid use disorder should
reoccurrence of psychiatric disorders, or it may work in receive non-opioid analgesics [e.g., acetaminophen, non-
reducing, masking, or enabling an adolescent to cope with steroidal anti-inflammatory drugs (NSAIDS)].5,8 Prior to
symptoms.2,15,16 Behaviors consistent with both SUD and prescribing medications that have the potential to be abused,
mental disorders may be confusing to dental providers. Pro- the practitioner should assess adolescent patients with risk
fessionals must be cautious not to assume clinical signs are factors such as active substance use, past substance abuse,
associated with substance abuse when, in fact, they are pre- current medications, and a family history of substance abuse.6
sentations consistent with mental disorders, and vice versa.2,6,8,15 For patients at high risk, the dentist should consider prescrib-
Such caution prevents inaccurate diagnoses and judgment or ing alternative medications with less abuse potential, closely
labelling of an adolescent patient, which could lead to monitoring the patient, reducing length of time between visits
emotional harm and diversion from necessary treatment.2,15,16 for refills, prescribing smaller amounts of liquid medications
Dentists are in a position to identify clinical manifestations or fewer pills, and educating both patients and parents about
of substance use, present brief interventions, and provide re- proper use and potential risks of prescription medications,
ferrals to medical providers or behavioral health or addiction including the risk of sharing them with others.6
specialists. They also can assist the patient and family in
finding treatment facilities, self-help groups, and community Policy statement
resources which address alcohol and drug abuse specific to The AAPD recognizes that an increasing number of adoles-
adolescents.6-8,17,18 When substance abuse is suspected or con- cents abuse alcohol and/or drugs.1,10 Providing dental care to
firmed, an empathetic, non-judgmental style of discussion adolescents with substance use disorders requires awareness
facilitates a trusting patient-doctor relationship.7 Asking of clinical manifestations and implementation of different
openended questions may garner more information as they treatment approaches. Therefore, the AAPD encourages dental
tend to be less threatening to the patient.7 Brief interventions professionals to:
may include educating the patient and/or family on health • gain knowledge of SUD and associated behavioral,
physiological, and cognitive effects in adolescents.

• use a specific adolescent medical history documenting for Substance Abuse Treatment; 2006. HHS publication
past history, current use, and previous treatments for no. (SMA) 15-4131. Available at: “http://www.ncbi.nlm.
substance abuse. nih.gov/books/NBK64119/#A85324”. Accessed June
• recognize behaviors, clinical signs, and symptoms of 24, 2016.
adolescent substance abuse. 6. National Institute on Drug Abuse. Principles of adoles-
• provide brief interventions to educate the adolescent and cent substance use disorder treatment: A research-based
his family regarding the risks of substance abuse. guide. Bethesda, Md.: National Institutes of Health;
• provide brief interventions for encouragement, support, 2014. NIH publication no. 14-7953. Available at: “https:
and positive reinforcement for avoiding substance use. //teens.drugabuse.gov/sites/default/files/podata_1_17_
• provide referrals to primary care providers or behavior- 14_0.pdf ”. Accessed June 13, 2016.
al health or addiction specialists for assessment and/or 7. Kulig JW. American Academy of Pediatrics Committee
treatment of SUD in adolescents when indicated. on Substance Abuse. Tobacco, alcohol, and other drugs:
• be familiar with community resources, such as self-help The role of the pediatrician in prevention, identification,
groups and treatment facilities, specific to adolescents and management of substance abuse. Pediatrics 2005;
with SUD. 115(3):816-21. Reaffirmed March, 2013.
• use local anesthetics containing vasoconstrictors with 8. Kulig J, Ammermann SD, Moreno MA, et al. Substance
caution in patients having a stimulant use disorder. abuse. In: Fisher MM, Aldermann EM, Kreipe RE,
• limit or decline use of nitrous oxide and anxiolytic or Rosenfeld WD, eds. American Academy of Pediatrics
sedative medications in adolescents with SUD. Textbook of Adolescent Health Care. Elk Grove Village,
• recommend non-opioid analgesics when pain manage- Ill.: American Academy of Pediatrics; 2011:1726-813.
ment is necessary. 9. Johnson LD, O’Malley, PM, Miech RA, Bachman JG,
• prescribe non-controlled substances or medications with Schulenberg JE. Monitoring the Future national survey
a low potential for abuse. results on drug use: 1975-2014: Overview, key findings
• prescribe medications that have the potential to be abused on adolescent drug use. Ann Arbor, Mich.: Institute
in small amounts or quantities, preferably with no refills. for Social Research, University of Michigan; 2015.
• respect patient confidentiality in accordance with state Available at: “http://www.monitoringthefuture.org/
and federal laws. pubs/monographs/mtf-overview2014.pdf ”. Accessed
June 24, 2016.
References 10. Centers for Behavioral Health Statistics and Quality.
1. Substance Abuse and Mental Health Services Administra- Behavioral health trends in the United States: Results
tion. Binge drinking: Terminology and patterns of use from the 2014 national survey on drug use and health.
analyzing internal and external partnerships. Available Rockville, Md.: Substance Abuse and Mental Health
at: “http://www.samhsa.gov/capt/tools-learning-resources/ Services Administration; 2015. HHS publication no.
binge-drinking-terminology-patterns”. Accessed June 24, SMA 15-4927, NSDUH series H-50. Available at: “http:
2016. //www.samhsa.gov/data/sites/default/files/NSDUH-
2. Center for Substance Abuse Treatment. Substance abuse FRR1-2014/NSDUH-FRR1-2014.pdf ”. Accessed June
treatment for persons with co-occurring disorders. Treat- 13, 2016.
ment Improvement Protocol (TIP) Series, No. 42. 11. Substance Abuse and Mental Health Services Adminis-
Rockville, Md.: Substance Abuse and Mental Health tration. Mental health and substance use disorders.
Services Administration; 2005. HHS publication no. Rockville, Md.; 2015. Available at: “http://www.samh
(SMA) 05-3922. Available at: “http://www.ncbi.nlm. sa.gov/disorders”. Accessed June 24, 2016.
nih.gov/books/NBK64184/#A74167”. Accessed June 24, 12. Partnership for Drug-Free Kids. Is your teen using? Signs
2016. and symptoms of substance abuse. Available at: “http://
3. National Institute on Drug Abuse. The science of drug www.drugfree.org/resources/is-your-teen-using-signs-
abuse and addiction: The basics. Bethesda, Md.: National and-symptoms-of-substance-abuse/”. Accessed June 24,
Institutes of Health; 2014. Available at: “http://www. 2016.
drugabuse.gov/publications/media-guide/science-drug 13. Williams JF, Storck M. American Academy of Pediatrics
-abuse-addiction-basics”. Accessed June 24, 2016. Committee on Substance Abuse; American Academy of
4. American Psychiatric Association. Diagnostic and Statis- Pediatrics Committee on Native American Child Health.
tical Manual of Mental Disorders. 5th ed. Arlington, Inhalant abuse. Pediatrics 2007;119(5):1009-17.
Va.: American Psychiatric Association; 2013:483. 14. Saini GK, Gupta ND, Prabhat KC. Drug addiction and
5. Center for Substance Abuse Treatment. Detoxification periodontal diseases. J Indian Soc Periodontol 2013;17
and substance abuse treatment. Treatment Improvement (5):587-91.
Protocol (TIP) Series, No. 45, Rockville, Md.: Center

15. Chan YF, Dennis ML, Funk RR. Prevalence and co- 19. Miller WR, Rollnick S. Applying motivational inter-
morbidity of major internalizing and externalizing viewing. In: Motivational Interviewing: Helping People
problems among adolescents and adults presenting to Change. 3rd ed. New York, N.Y.: The Guilford Press;
substance abuse treatment. J Subst Abuse Treat 2008; 2013:335-51.
34(1):14-24. 20. Joffe A. Confidentiality in dealing with adolescents. In:
16. Garito PJ. Assessing and treating psychiatric co-morbidity Graham AW, Schultz TK, Mayo-Smith MF, et al., eds.
in chemically abusing adolescents. In: O’Connell D, Principles of Addiction Medicine. 3rd ed. Chevy Chase,
Beyer E, eds. Managing the Dually Diagnosed Patient: Md.: American Society of Addiction Medicine; 2003:
Clinical Issues and Clinical Approaches. 2nd ed. New 1555-7.
York, N.Y.: The Haworth Press; 2002:153-88. 21. Klein-Schwartz W. Abuse and toxicity of methylphen-
17. Dean JA. Examination of the mouth and other relevant idate. Curr Opin Pediatr 2002;14(2):219-23.
structures. In: McDonald and Avery’s Dentistry for the 22. Hamamoto DT, Rhodus NL. Methamphetamine abuse
Child and Adolescent. 10th ed. St. Louis, Mo.: Mosby and dentistry. Oral Dis 2009;15(1):27-37.
Elsevier; 2016:13-4. 23. Friedlander AH, Yagiela JA, Paterno VI, Mahler ME.
18. American Dental Association. Statement on provision The pathophysiology, medical management, and dental
of dental treatment for patients with substance use implications of children and young adults having
disorders. October, 2005. Available at: “http://www.ada. attention-deficit hyperactivity disorder. J Calif Dent
org/en/about-the-ada/ada-positions-policies-and- Assoc 2003;31(9):669-78.
statements/provision-of-dental-treatment-for-patients
-with-substance-abuse”. Accessed June 24, 2016.

ORAL HEALTH POLICIES: HPV VACCINATIONS
Policy on Human Papilloma Virus Vaccinations

Revised How to Cite: American Academy of Pediatric Dentistry. Policy on
2020 human papilloma virus vaccinations. The Reference Manual of Pedi-
atric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
2020:102-3.
Purpose increased availability of the HPV vaccines, HPV-related

The American Academy of Pediatric Dentistry (AAPD) OOPC incidence has continued to increase significantly.12
recognizes there is a link between human papilloma virus In 2016, the Centers for Disease Control and Prevention
(HPV) and development of oral pharyngeal cancers. The (CDC) Advisory Committee on Immunization Practices
purpose of this policy is to provide a perspective on dental (ACIP) recommended a two-dose schedule for children
provider’s role in discussing oral cancers and their associations younger than 15 years of age with both doses 6-12 months
with HPV, and HPV vaccination for age-appropriate patients. apart. 13 For children age 15 or older at the time of initial
vaccination and for those with immunocompromising
Methods conditions, a three-dose series is recommended. 13 The
This policy was developed by the Council on Clinical Affairs American Academy of Pediatrics (AAP) updated their HPV
and adopted in 2017.1 This revision is based on a review of vaccination policy in 2017 to reflect the ACIP/CDC
current dental and medical literature. An electronic search recommendations. 14 Low compliance rates for completion
®
was conducted using the PubMed /MEDLINE database
using the terms: HPV vaccines, HPV and oral cancer, HPV
of the vaccination series are due to access, willingness of
physicians to discuss with parents, and cost.14-17
®
and cancer, Gardasil and prevention of cancer; fields: all;
limits: within the last 10 years, humans, English, birth
Adolescent patients have unique needs related to oral
healthcare. Anticipatory guidance for adolescent patients
through age 99. The search returned over 5,296 articles. Papers includes tobacco and nutritional counseling.18,19 Given that
for review were chosen from this list and from the references dental professionals are already involved in secondary and
within selected articles. tertiary prevention and, to a limited extent, in the treatment of
OOPC, offering primary prevention in dental clinics seems a
Background logical and clinically-appropriate approach. As adolescent
HPV is associated with anogenital, skin, and oral and oropha- patients tend to see the dentist twice yearly and more often
ryngeal cancers (OOPC)2-4. It also is observed in oral squa- than their medical doctor, this is a window of opportunity
mous cell carcinoma, the most common type of OOPC. 5 for the dental professional to provide counseling to the patient
Based on epidemiological trends, 53,260 new cases and 10,750 and parent about HPV’s link to oral cancer and potential
deaths due to OOPC were expected to occur in 2019.6 HPV benefits of the HPV vaccine.20
is a critical factor, with the HPV 16 strain being the most
prevalent. 7 The association between HPV infection and Policy statement
OOPC may be responsible for the recent epidemiologic change The AAPD supports measures that prevent OOPC, including
with OOPC affecting younger population groups. the prevention of HPV infection, a critical factor in the
Vaccines for prevention of HPV infections via subtypes development of oral squamous cell carcinoma.
16 and 18 have been available since 2006.8 The Centers for The AAPD encourages oral health care providers to:
Disease Control and Prevention (CDC) found that the preva- • educate patients, parents, and guardians on the serious
lence of HPV infection decreased 56 percent among females health consequences of OOPC and the relationship
aged 14-19 years since the vaccine was introduced.8 A recent of HPV to OOPC.
study showed 88 percent reduction in prevalence in females • counsel patients, parents, and guardians regarding the
and males age 18-33 years.10 HPV vaccine efficacy against HPV vaccination, in accordance with CDC recommen-
anal and oral infection is high and similar to that against dations, as part of anticipatory guidance for adolescent
cervical infection.11 Because the same viral strains are strongly patients.
associated with OOPC, it is reasonable to assume that HPV
vaccines play an important role in oral pharyngeal cancer
ABBREVIATIONS
prevention. Although there are no studies showing that the
HPV vaccine prevents the development of OOPC, it is of Pediatric Dentistry. ACIP: Advisory Committee on Immunization
reasonable to postulate the vaccine’s potential since the vaccine Practices. CDC: Centers for Disease Control and Prevention. HPV:
has been shown to prevent HPV infection. 9 Despite the Human papilloma virus. OOPC: Oral and oropharyngeal cancer.

ORAL HEALTH POLICIES: HPV VACCINATIONS
• routinely examine patients for oral signs of and changes 11. Beachler CK. Multisite HPV 16/18 vaccine efficacy
consistent with OOPC. against cervical, anal, and oral HPV infection. J Natl
• follow current literature and consider incorporating Canc Inst 2015;108(1):djv302. Available at: “https://
other approaches for HPV prevention in their practices www.ncbi.nlm.nih.gov/pmc/articles/PMC4862406/”.
so as to minimize the risk of disease transmission. Accessed October 31, 2020.
12. Senkomago V, Henley SJ, Thomas CC, Mix JM.
References Markowitz LE, Saraiya M. Human papillomavirus—
1. American Academy of Pediatric Dentistry. Policy on Attributable cancers—United States 2012-2015. MMWR
human papilloma virus vaccinations. Pediatr Dent 2017; Mor Mortal Wkly Rep 2019;68:724-8. Accessed January
39(6):81-2. 3, 2020.
2. National Cancer Institute. HPV and cancer. 2014. Avail- 13. Meites E, Kempe A, Markowitz LE. Use of a 2-dose
able at: “https://www.cancer.gov/about-cancer/causes- schedule for human papillomavirus vaccination —
prevention/risk/infectious-agents/hpv-and-cancer”. Updated recommendations of the Advisory Committee
Accessed May 11, 2020. on Immunization Practices. Morb Mortal Wkly Rep
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cancer-org/research/cancer-facts-and-statistics/annual- October 31, 2020.
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-2019.pdf ”. Accessed January 3, 2020. mentation Guidance Updated February 2017. Available
4. Cogliano V, Baan R, Straif K, Grosse Y, Secretan B, El at: “https://www.aap.org/en-us/Documents/immunization
Ghissassi F. Carcinogenicity of human papillomaviruses. _hpvimplementationguidance.pdf ”. Accessed January 3,
World Health Organization International Agency for 2020.
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2011;71(2):136-42. vaccine hesitancy in the United States. Hum Vaccin
6. American Cancer Society. Cancer A-Z. Oral Cavity and Immunother 2013;9(12):2643-8.
Oropharyngeal Cancer: Causes, Risk Factors, and Preven- 17. Henrikson NB, Opel DJ, Grothaus L, et al. Physician
tion. Available at: “https://www.cancer.org/cancer/oral communication training and parental vaccine hesitancy:
-cavity-and-oropharyngeal-cancer/causes-risks-prevention. A randomized trial. Pediatrics 2015;136(1):70-9.
html”. Accessed May 11, 2020. 18. American Academy of Pediatric Dentistry. Adolescent oral
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Garcia I. Oral cavity and oropharyngeal cancer incidence Chicago, Ill.: American Academy of Pediatric Dentistry;
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“https://www.ncbi.nlm.nih.gov/pmc/articles/PMC453 examination, preventive dental services, anticipatory
2587/”. Accessed January 3, 2020. guidance/counseling, and oral treatment for infants, chil-
8. Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent dren, and adolescents. The Reference Manual of Pediatric
human papillomavirus vaccine: Recommendations of the Dentistry. Chicago, Ill.: American Academy of Pediatric
Advisory Committee on Immunization Practices (ACIP). Dentistry; 2020:232-42.
MMWR Recomm Rep 2007;56(RR-2):1-24. 20. Irwin CE Jr, Adams SH, Park MJ, Newacheck PW.
9. Markowitz LE, Hariri S, Lin C, et al. Reduction in human Preventive care for adolescents: Few get visits and fewer
papillomavirus (HPV) prevalence among young women get services. Pediatr 2009;123(4):e565-72. Available at:
following HPV vaccine introduction in the United States, “https://dx.doi.org/10.1542/peds.2008-2601”. Accessed
National Health and Nutrition Examination Surveys, January 3, 2020.
2003-2010. J Infect Dis 2013;208(3):385-93.
10. Chaturvedi AK, Graubard BI, Broutian T, et al. Effect
of prophylactic human papillomavirus (HPV) vaccina-
tion on oral HPV infections among young adults in the
United States. J Clin Oncol 2018;36(3):262-7.

ORAL HEALTH POLICIES: INTRAORAL / PERIORAL PIERCING
Policy on Intraoral / Perioral Piercing and Oral

Jewelry / Accessories
2016 intraoral/perioral piercing and oral jewelry/accessories. The Reference
Purpose (e.g., grills) has been documented to cause dental caries.34,

The American Academy of Pediatric Dentistry recognizes the Unregulated piercing parlors and techniques have been iden-
importance of educating the public and health professionals tified by the National Institutes of Health as a possible vector
on the health implications of intraoral/perioral piercings and for disease transmission (e.g., hepatitis, tetanus, tuberculosis)
oral jewelry/accessories. and as a cause of bacterial endocarditis in susceptible patients.1
Between January 1, 2002 and December 31, 2008, an estimated
Methods 24,459 patients presented to U.S. emergency departments with
This policy was developed by the Council on Clinical Affairs oral piercing-related injuries.23 The annual average number of
and adopted in 2000. This document is a revision of the estimated emergency department visits was 3,494, with a range
previous version, revised in 2011. The update included a from 2,675 (in 2005) to 4,380 (in 2006).23
new review of current dental and medical literature, including
®
a search of the PubMed /MEDLINE and Cochrane Central
Register of Controlled Trials electronic databases through
Policy statement
The American Academy of Pediatric Dentistry strongly opposes
September, 2015 with the terms: oral jewelry, body piercing, the practice of piercing intraoral and perioral tissues and use
and oral piercing paired with dental and oral piercing; fields: of jewelry on intraoral and perioral tissues due to the poten-
all; limits: within the last 10 years, humans, English, birth tial for pathological conditions and sequelae associated with
through age 99. Four hundred eighty-one articles matched these practices.
these criteria. Because of so many papers identified through
electronic searches, alternate strategies such as appraisal of References
references from recent evidence-based reviews, controlled clin- 1. Durosaro O, El-Azhary R. A 10-year retrospective study
ical trials, and meta-analysis and hand searches were performed. on palladium sensitivity. Dermatitis 2009;20(4):208-13.
This strategy yielded 85 manuscripts which were evaluated 2. Ziebolz D, Hildebrand A, Proff P, Rinke S, Hornecker
further by abstract. Papers for review were chosen from this E, Mausberg R. Long-term effects of tongue piercing –
list and from the references within selected articles. A case control study. Clin Oral Investig 2012;16(1):231-7.
3. Plessas A, Pepelassi E. Dental and periodontal compli-
Background cations of lip and tongue piercing: Prevalence and
The use of intraoral jewelry and piercings of oral and perioral influencing factors. Aust Dent J 2012;57(1):71-8.
tissues have been gaining popularity among adolescents and 4. Hennequin-Hoenderdos NL, Slot DE, Van der Weijden
young adults. Intraoral jewelry or other oral accessories may GA. The incidence of complications associated with
lead to increased plaque levels, gingival inflammation and/or lip and/or tongue piercings: A systematic review. Int J
recession, caries, diminished articulation, and metal allergy.1-5 Dent Hyg 2016;14(1):62-73.
Oral piercings involving the tongue, lips, cheeks, and uvula 5. Reyes P. Hole-y mouth jewelry! Piercings could lead to
have been associated with pathological conditions including anterior tooth loss. J Calif Dent Assoc 2008;36(9):
pain, infection, scar formation, tooth fractures, metal hyper- 651, 655.
sensitivity reactions, localized periodontal disease, speech 6. National Institutes of Health. Management of hepatitis
impediment, Ludwig’s angina, hepatitis, and nerve damage.6-29 C. NIH Consensus Conference Statement June 10-12,
Specifically, gingival recession was evident in seven to 50 2002. Available at: “https://consensus.nih.gov/2002/200
percent of all patients with lip piercing and six to 44 percent 2HepatitisC2002116html.htm”. Accessed June 29, 2016.
of patients with tongue piercing. Permanent tooth injuries 7. American Dental Association. ADA statement on intra-
were observed in 26 percent of patients with lip piercing oral/perioral piercings and tongue splitting, Amended
and 37-46 percent of patients with tongue piercings.2-4 Life- October, 2012. Available at: “http://www.ada.org/en/
threatening complications associated with oral piercings have member-center/oral-health-topics/oral-piercing”. Accessed
been reported, including bleeding, edema, endocarditis, and June 14, 2016.
airway obstruction.6-33 Additionally, the use of dental jewelry

ORAL HEALTH POLICIES: INTRAORAL / PERIORAL PIERCING
8. Stein T, Jordan JD. Health considerations for oral piercing 21. DeBoer S, McNeil M, Amundson T. Body piercing and
and the policies that influence them. Tex Dent J 2012; airway management: Photo guide to tongue jewelry
129(7):687-93. removal techniques. J Am Assoc Nurse Anesth 2008;76
9. Hennequin-Hoenderdos NL, Slot DE, Van der Weijden (1):19-23.
GA. The prevalence of oral and perioral piercings in 22. Golz L, Papageorgiou SN, Jager A. Nickel hypersensi-
young adults: A systematic review. Int J Dent Hyg 2012; tivity and orthodontic treatment: A systematic review and
10(3):223-8. meta-analysis. Contact Dermatitis 2015;73(1):1-14.
10. Vilchez-Perez MA, Fuster-Torres MA, Figueiredo R, 23. Gill, JB, Karp JM, Kopycka-Kedzierawski DT. Oral
Valmaseda-Castellon E, Gay-Escoda C. Periodontal health piercing injuries treated in United States emergency
and lateral lower lip piercings: A split-mouth cross- departments, 2002-2008. Pediatr Dent 2012;34(1):
sectional study. J Clin Periodontol 2009;36(7):558-63. 56-60.
11. DeMoor RJ, DeWitte AM, Debuyne MA. Tongue 24. Vieira EP, Ribeiro AL, Pinheiro Jde J, Alves Sde M. Oral
piercing and associated oral and dental complications. piercings: Immediate and late complications. J Oral
Endod Dent Traumatol 2000;16(5):232-7. Maxillofac Surg 2011;69(12):3032-7.
12. Price SS, Lewis MW. Body piercing involving oral sites. 25. Levin L, Zadik Y. Oral piercing: Complications and side
J Am Dent Assoc 1997;128(7):1017-20. effects. Am J Dent 2007;20(5):340-4.
13. Fors R, Stenberg B, Stenlund H, Persson M. Nickel 26. Kloppenburg G, Maessen J. Streptococcus endocarditis
allergy in relation to piercing and orthodontic appliances– after tongue piercing. J Heart Valve Dis 2007;16(3):
A population study. Contact Dermatitis 2012;67(6): 328-30.
342-50. 27. Lopez-Jornet P, Navarro-Guardiola C, Camacho-Alonso
14. Inchingolo F, Tatullo M, Abenavoli FM, et al. Oral F, Vicente-Ortega V, Yanez-Gascon J. Oral and facial
piercing and oral diseases: A short time retrospective piercings: A case series and review of the literature. Int J
study. Int J Med Sci 2011;8(8):649-52. Dermatol 2006;45(7):805-9.
15. Maspero C, Farronato G, Giannini L, Kairyte L, Pisani 28. American Dental Association. For the dental patient: The
L, Galbiati G. The complication of oral piercing and piercing truth about tongue splitting and oral jewelry.
the role of dentist in their prevention: A literature review. J Am Dent Assoc 2012;143(7):814.
Stomatologija 2014;16(3):118-24. 29. Martinello R, Cooney E. Cerebellar brain abscess asso-
16. Berenguer G, Forrest A, Horning GM, Towle HJ, ciated with tongue piercing. Clin Infect Dis 2003;36
Karpinia K. Localized periodontitis as a long-term effect (2):32-4.
of oral piercing: A case report. Compend Contin Educ 30. Pires IL, Cota LO, Oliveira AC, Costa JE, Costa FO.
Dent 2006;27(1):24-7. Association between periodontal condition and use of
17. Klevens RM, Hu DJ, Jiles R, Holmberg SD. Evolving tongue piercing: A case-control study. J Clin Periodontol
epidemiology of hepatitis C virus in the United States. 2010;37(8):712-8.
Clin Infect Dis 2012;55(Suppl 1):S3-9. 31. Kapferer I, Beier US. Lateral lower lip piercing--prevalence
18. Hennequin-Hoenderdos NL, Slot DE, Van der Weijden of associated oral complications: A split-mouth cross-
GA. Complications of oral and perioral piercings: A sectional study. Quintessence Int 2012;43(9):747-52.
summary of case reports. Int J Dent Hyg 2011;9(2):101-9. 32. Kapferer I, Beier US, Jank S, Persson RG. Randomized
19. Firoozmand L, Paschotto D, Almeida J. Oral piercing controlled trial: Lip piercing: The impact of material on
complications among teenage students. Oral Health Prev microbiological findings. Pediatr Dent 2013;35(1):E23-8.
Dent 2009;7(1):77-81. 33. Kapferer I, Beier US, Persson RG. Tongue piercing: The
20. García-Pola M, García-Martin J, Varela-Centelles P, effect of material on microbiological findings. J Adolesc
Bilbao-Alonso A, Cerero-Lapiedra R, Seoane J. Oral and Health 2011;49(1):76-83.
facial piercing: Associated complications and clinical 34. Hollowell WH, Childers NK. A new threat to adolescent
repercussion. Quintessence Int 2008;39(1):51-9. oral health: The grill. Pediatr Dent 2007;29(4):320-2.

ORAL HEALTH POLICIES: SPORTS-RELATED OROFACIAL INJURIES
Policy on Prevention of Sports-Related Orofacial

Injuries
2018 prevention of sports-related orofacial injuries. The Reference Manual
Dentistry; 2020:106-11.
Purpose total (sport and not-sport related) dental injuries that

The American Academy of Pediatric Dentistry (AAPD) presented that presented to United States emergency rooms
recognizes the prevalence of sports-related orofacial injuries from 1990-2003.3 In all age groups, males were more likely to
in our nation’s youth and the need for prevention. This policy have dental injuries than females.3
is intended to educate dental professionals, health care pro- It has been demonstrated that dental and facial injuries
viders, and educational and athletic personnel on the can be reduced significantly by introducing mandatory pro-
prevention of sports-related orofacial injuries. tective equipment.8,9 Currently in the United States, high
school football, lacrosse, and ice hockey require protective
Methods equipment.10 Popular sports such as baseball, basketball,
This policy was developed by the Clinical Affairs Committee soccer, softball, wrestling, volleyball, and gymnastics lag far
and adopted in 1991, and was revised by the Council of Clin- behind in injury protection for girls and boys. Baseball and
ical Affairs. This document is a revision of the previous version, basketball have been shown to have the highest incidence of
revised in 2013. The revision of this policy is based upon a sports-related dental injuries in children seven to 17 years of
review of current dental and medical literature related to age.1 More specifically, baseball accounted for the most dental
orofacial injuries, including their prevention. Database searches injuries within the seven to 12 year old age group, while
were performed using the terms: sports injuries, injury preven- basketball was the most frequent sport associated with dental
tion, dental injuries, orofacial injuries. Seventy-seven references injuries in the 13 to 17 year age group.3 Youths participating
were chosen from this method and from references within in leisure activities such as skateboarding, inline or roller
selected articles. The policies, recommendations, and listed skating, and bicycling also benefit from appropriate protective
references of the Academy for Sports Dentistry (ASD) and equipment.11-14 A large national survey confirmed the bicycle
the International Association of Dental Traumatology were as the most common consumer sports product related to
consulted as valuable resources in preparation of this document. dental injuries in children, followed by playground equipment,
other riding equipment (skates, inline skates), and trampolines.3
Background The use of the trampoline provides specialized training for
The tremendous popularity of organized youth sports and certain sports. However, when used recreationally, a signifi-
the high level of competitiveness have resulted in a significant number of head and neck injuries occurs, with head
cant number of dental and facial injuries.1,2 From 1990- injuries most commonly a result of falls.15 The American
2003, there was an average of 22,000 dental injuries annually Academy of Pediatrics (AAP) recommends practitioners advise
in children less than 18 years of age.3 This was approximately patients and their families against recreational trampoline use
31.6 dental injuries per 100,000 children and adolescents. In and discuss that current safety measures have not decreased
2007, it was reported that approximately 46 million youths injury rates significantly.15 The AAP also states that practi-
in the United States were involved in some form of sports tioners “should only endorse use of trampolines as part of a
over the past decade.4 It has been estimated that 30 million structured training program with appropriate coaching, super-
children in the United States participate in organized sport vision, and safety measures in place”.15
programs.5 All sporting activities have an associated risk of Studies of dental and orofacial athletic injuries are reported
orofacial injuries due to falls, collisions, contact with hard throughout the medical and dental literature.16-19 Injury rates
surfaces, and contact from sports-related equipment. A vary greatly depending on the size of the sample, the sample’s
systematic review reported between 10-61 percent of athletes
reported experiencing dental trauma.6 A 10 year study of
3,385 craniomaxillofacial trauma cases presenting to an oral ABBREVIATIONS
and maxillofacial surgery department found 31.8 percent of AAP: American Academy of Pediatrics. AAPD: American Academy
Pediatric Dentistry. ASD: Academy of Sports Dentistry. ASTM:
injuries in children occurred during sports activities.7 Children American Society for Testing and Materials.
ages 17 years and younger represented 80.6 percent of the

geographic location, the ages of the participants, and the spe- to identify the risk factors involved in various sports.34 This
cific sports involved in the study.16-20 Rates of traumatic dental index is based upon a defined set of risk factors that predict
injuries also differ in regards to the athlete’s level of competi- the chance of injury including demographic information (age,
tion; less-professional athletes exhibit a higher prevalence of gender, dental occlusion), protective equipment (type/usage),
sports-related injuries.18 Most of the current data regarding velocity and intensity of the sport, level of activity and expo-
injuries comes from the National High School Sports-Related sure time, level of coaching and type of sports organization,
Injury Surveillance Study and captures information such as whether the player is a focus of attention in a contact or non-
exposure (competition vs. practice), the injury, details of the contact sport, history of previous sports-related injury, and
event, and type of protective equipment used.21 Data from this the situation (practice vs. game).34 Behavioral risk factors
source found that in 2016-2017 school year, of the 699,441 (e.g., hyperactivity) also have been associated significantly with
injuries reported during competition, 223,623 (32 percent) injuries affecting the face and/or teeth.35,36
occurred to the head/face; another 91,410 occurred during While this predictive index looked at contact versus non-
practice.21 A similar study using this database followed athletes contact sport as a factor, non-contact sports can carry signifi-
from 2008-2014 and found the rate of dental injuries in cant risk. For example, basketball is one of the sports with the
competition was three times higher than in practice.21 For the highest incidence of dental injury, but these injuries usually
majority of these reported injuries, the athlete was not wearing involve player-player contact whereas greater than 87 percent
a mouthguard.20 Review of this data-base found the highest of all dental injuries sustained by baseball, softball, and field
rates of dental injuries in high school athletes occurred in girls’ hockey players are due to player-object contact.20
field hockey and boys’ basketball.20 Although the statistics The frequency of dental trauma is significantly higher for
vary, many studies reported that dental and orofacial injuries children with increased overjet (greater than 6 millimeters) and
occurred regularly and concluded that participation in sports inadequate lip coverage.37,38 A dental professional may be able
carries a considerable risk of injury.7,12,17,18 to modify these risk factors. Initiating preventive orthodontic
Consequences of orofacial trauma for children and their treatment in early- to middle-mixed dentition of patients with
families are substantial because of potential for pain, psycho- an overjet greater than three millimeters has the potential to
logical effects, and economic implications. Children with reduce the severity of traumatic injuries to permanent incisors.37
untreated trauma to permanent teeth exhibit greater impacts Although some sports-related traumatic injuries are un-
on their daily living than those without any traumatic avoidable, most can be prevented.39-41 Helmets, facemasks, and
injury.22,23 The yearly costs of all injuries, including orofacial mouthguards have been shown to reduce both the frequency
injuries, sustained by young athletes have been estimated to and severity of dental and orofacial trauma.39 While facemasks
be 500 million dollars24 and as high as 1.8 billion dollars.5 may not significantly reduce the risk of orofacial trauma due
Significant costs can accrue over a patient’s lifetime for to player-player contact, they might have a significant effect
restorative, endodontic, prosthodontic, implant, or surgical with player-object contact.9 The protective and positive results
treatment(s) resulting from dentoalveolar trauma. It has of wearing a mouthguard have been demonstrated in nu-
been suggested that the lifetime cost of an avulsed tooth in a merous epidemiological surveys and tests.18,42-46 However, few
teenage athlete can reach $20,000, exceeding the maximum sports have regulations that require their use. The National
benefits for most insurance companies.25 Traumatic dental Federation of State High School Associations mandates
injuries have additional indirect costs that include children’s mouthguards only for football, ice hockey, lacrosse, and
hours lost from school and parents’ hours lost from work, field hockey and for wrestlers wearing braces.10 Several states
consequences that disproportionately burden lower income, have attempted to increase the number of sports which
minority, and non-insured children.26-29 mandate mouthguard use, with various degrees of success and
The majority of sport-related dental and orofacial injuries acceptance. Four states (Maine, Massachusetts, Minnesota,
affect the upper lip, maxilla, and maxillary incisors, with and New Hampshire) have been successful in increasing the
50 to 90 percent of dental injuries involving the maxillary number of sports requiring mouthguard use to include sports
incisors.16,17,25,30 The most common injuries in order of inci- such as soccer, wrestling, and basketball.41,47,48 It is likely that
dence are lacerations, crown fractures, and avulsions.7 Crown the mandated mouthguard rule has not expanded to other
fractures are the most common injury to permanent teeth,31,32 sports due to complaints by athletes, parents, and coaches that
followed by subluxations and avulsions.32 While use of a mouthguards interfere with how the game is played and the
mouthguard can protect the upper incisors, it may not protect athletes’ enjoyment.47,49 Regardless of the relatively limited use
against soft tissue injuries. However, studies have shown that of mouthguards in sports, the American Dental Associations
even with a mouthguard in place, dentoalveolar injuries still and International Academy of Sports Dentistry currently rec-
can occur.33 ommend the use of mouthguards in 29 sports or activities.50
Identifying patients who participate in sports and recrea- Initially used by professional boxers, the mouthguard has
tional activities allows the healthcare provider to recommend been used as a protective device since the early 1900s.6,17,51 The
and implement preventive protocols for individuals at risk for mouthguard, also referred to as a gumshield or mouth protec-
orofacial injuries. In 2000, a predictive index was developed tor, is defined as a “resilient device or appliance placed inside

the mouth to reduce oral injuries, particularly to teeth and The ASD “recommends the use of a properly fitted mouth-
surrounding structures.”52 The mouthguard was constructed to guard. It encourages the use of a custom fabricated mouth-
“protect the lips and intraoral tissues from bruising and guard made over a dental cast and delivered under the
laceration, to protect the teeth from crown fractures, root supervision of a dentist. The ASD strongly supports and
fractures, luxations, and avulsions, to protect the jaw from encourages a mandate for use of a properly-fitted mouthguard
fracture and dislocations, and to provide support for eden- in all collision and contact sports.”65 During fabrication of
tulous space.”53 The mouthguard helps to prevent fractures the mouthguard, it is recommended to establish proper
and dislocations of teeth by providing cushioning from the anterior occlusion of the maxillary and mandibular arches as
blow and redistributing shock during forceful impacts and this will prevent or reduce injury by better absorbing and dis-
decreases the likelihood of jaw fracture by a similar mecha- tributing the force of impact.65 The practitioner also should
nism and also by stabilizing the mandible.54 The mouthguard consider the patient’s vertical dimension of occlusion, personal
acts as a buffer between the soft and hard dento-oral structures comfort, and breathing ability. 63 By providing cushioning
to prevent soft tissue injuries by separating the teeth from the between the maxilla and mandible, mouthguards also may
tissues.54 Recent data suggests that a properly fitted mouth- reduce the incidence or severity of condylar displacement
guard of 3.0 millimeter thickness might reduce the incidence injuries as well as the potential for concussions.55,66
of concussion injuries from a blow to the jaw by positioning Due to the continual shifting of teeth in orthodontic
the jaw to absorb the impact forces which, without it, would therapy, the exfoliation of primary teeth, and the eruption of
be transmitted through the skull base to the brain.55 permanent teeth, a custom-fabricated mouthguard may not
The American Society for Testing and Materials (ASTM) fit the young athlete soon after the impression is obtained.67
classifies mouthguards by three categories56: Several block-out methods used in both the dental operatory
1. Type I – Custom-fabricated mouthguards are produced and laboratory may incorporate space to accommodate for
on a dental model of the patient’s mouth by either the future tooth movement and dental development. 67 By anti-
vacuum-forming or heat-pressure lamination technique.39 cipating required space changes, a custom fabricated mouth-
The ASTM recommends that for maximum protection, guard may be made to endure several sports seasons.67
cushioning, and retention, the mouthguard should cover Parents play an important role in the acquisition of a
all teeth in at least one arch, customarily the maxillary mouthguard for young athletes. In a 2004 national fee survey,
arch, less the third molar.56 A mandibular mouthguard is custom mouthguards ranged from $60 to $285.54.68 In a
recommended for individuals with a Class III malocclu- study to determine the acceptance of the three types of
sion. The custom-fabricated type is superior in retention, mouthguards by seven and eight-year-old children playing
protection, and comfort.39,54,57-60 When this type is not soccer, only 24 percent of surveyed parents were willing to pay
available, the mouth-formed mouthguard is preferable to $25 for a custom mouthguard.68 Thus, cost may be a barrier.68
the stock or preformed mouthguard.60-63 However, a more likely barrier may be that children do not
2. Type II – Mouth-formed, also known as boil-and-bite, accept mouthguard use easily. In a study of children receiving
mouthguards are made from a thermoplastic material mouthguards at no cost, 29 percent never wore the mouth-
adapted to the mouth by finger, tongue, and biting guard, 32 percent wore it occasionally, 15.9 percent wore it
pressure after immersing the appliance in hot water.52 initially but quit wearing it after one month, and only 23.2
Available commercially at department and sporting-goods percent wore the mouthguard when needed.69
stores as well as online, these are the most commonly used Attitudes of officials, coaches, parents, and players about
among athletes but vary greatly in protection, retention, wearing mouthguards influence their usage.49 Although coaches
comfort, and cost.39,42 are perceived as the individuals with the greatest impact on
3. Type III – Stock mouthguards are purchased over-the- whether or not players wear mouthguards, parents view them-
counter. They are designed for use without any modifi- selves as equally responsible for maintaining mouthguard
cation and must be held in place by clenching the teeth use.49,70 However, surveys of parents regarding the indications
together to provide a protective benefit.45 Clenching a for mouthguard usage reveal a lack of complete understanding
stock mouthguard in place can interfere with breathing of the benefits of mouthguard use.70 Compared to other forms
and speaking and, for this reason, stock mouthguards of protective equipment, mouthguard use received only
are considered by many to be less protective.50 Despite moderate parental support in youth soccer programs. 71
these shortcomings, the stock mouthguard could be the A 2009 survey commissioned by the American Association
only option possible for patients with particular clinical of Orthodontists reported that 67 percent of parents stated
presentations (e.g., use of orthodontic brackets and their children do not wear a mouthguard during organized
appliances, periods of rapidly changing occlusion during sports.72 The survey also found that 84 percent do not wear
mixed dentition).42,60,64 mouthguards while participating in organized sports because
it is not required, even though other protective equipment
(e.g., helmets, shoulder pads) is mandatory.72 Players’ per-
ceptions of mouthguard use and comfort largely determine

their compliance and enthusiasm. 56,73-75 Realizing athletes’ References

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ORAL HEALTH POLICIES: USE OF DENTAL BLEACHING
Policy on the Use of Dental Bleaching for Child

and Adolescent Patients
2019 the use of dental bleaching for child and adolescent patients.
Purpose may vary significantly during the mixed dentition. Full arch
The American Academy of Pediatric Dentistry recognizes that cosmetic bleaching during this developmental stage, however,
the desire for dental whitening by pediatric and adolescent would result in mismatched dental appearance once the child
patients has increased. This policy is intended to help pro- is in the permanent dentition. Adolescents present with
fessionals and patients make informed decisions about the unique dental needs, and the impact of tooth discoloration on
indications, efficacy, and safety of internal and external bleach- an adolescent’s self-image could be considered an indication
ing of primary and young permanent teeth and incorporate for bleaching.8 Tooth whitening has been successful in adoles-
such care into a comprehensive treatment plan. cent patients using typical bleaching agents, 8 but research is
lacking on the effects of bleaching on the primary dentition.
Methods Dental whitening may be accomplished by using either
This policy was developed by the Council on Clinical Affairs professional or at-home bleaching modalities. Advantages of
and adopted in 2004. This document is an update from the in-office whitening or whitening products dispensed and
last revision in 2014. This revision included a new literature monitored by a dental professional include:
®
dental bleaching, dental whitening, and tooth bleaching;
• an initial professional examination to help identify causes
of discoloration and clinical concerns with treatment
fields: all; limits: within the last 10 years, humans, English, (e.g., existing restorations, side effects).
clinical trials, and birth through age 18. Over 350 articles • professional control and soft-tissue protection.
were selected and reviewed. Additional information was ob- • patient compliance.
tained from reviewing references within selected articles. • rapid results.
• immediate attention to teeth sensitivity and other adverse
Background effects.
The desire for improved dental esthetics has fueled innovations
in dental materials. Patients, parents, and the news media The pretreatment professional assessment helps identify
request information on dental whitening for children and pulpal pathology that may be associated with a single discol-
adolescents with increasing frequency. In addition, increased ored tooth. This examination also identifies restorations that
demand for bleaching materials and services has affected are faulty or could be affected by the bleaching process and
both the variety and availability of dental bleaching products the associated costs for replacing such restorations to maximize
on the market. esthetic results.8-12 By using photographs and/or a shade guide,
Discoloration of teeth is classified by etiology. 1 Clinical the dentist can document the effectiveness of treatment. In
indications for internal or external dental whitening for addition to providing in-office bleaching procedures, a dentist
individual teeth may include discoloration resulting from a may fabricate custom trays for at-home use of a bleaching
traumatic injury (i.e., calcific metamorphosis, darkening with product. Custom trays ensure intimate fit and fewer adverse
devitalization), irregularities in enamel coloration of a perma- gingival effects.13 Over-the-counter products for at-home use
nent tooth due to trauma or infection of the related primary include bleaching gels, whitening strips, brush-on agents,
tooth, or intrinsic discoloration/staining (e.g., fluorosis, tetra- toothpaste, mints, chewing gum, and mouth rinse. Their main
cycline staining). 2-7 Teeth staining from metals (e.g., iron advantages include patient convenience and lower associated
supplements) or consumption of tea, coffee, soft drinks, costs.
alcohol, and certain foods is extrinsic and easier to treat Peroxide-containing whiteners or bleaching agents improve
compared to intrinsic factors whether congenital or acquired. the appearance by changing the tooth’s intrinsic color. The
Severe discolorations may be best treated with microabrasion professional-use products usually range from 10 percent car-
and subsequent bleaching to achieve desirable results.8 bamide peroxide (equivalent to about three percent hydrogen
Due to the difference in the thickness of enamel of primary peroxide) to 38 percent carbamide peroxide (equivalent to
and permanent teeth, tooth coloration within a dental arch approximately 13 percent hydrogen peroxide). In-office

bleaching products require isolation with a rubber dam or a Of growing concern is the preponderance of non-dental
protective gel to shield the gingival soft tissues. Home-use professionals offering teeth whitening services to the public.49
bleaching products contain lower concentrations of hydrogen Tooth whitening is defined as any process to whiten, lighten,
peroxide or carbamide peroxide.2-4,14 Efficacy and long-term or bleach teeth.49 Teeth-whitening kiosks and beauty salons
outcomes of home whitening products will vary according to and retail stores are providing whitening services and dis-
the concentration of peroxide used and the severity of the pensing teeth whitening agents.19,50 Dental organizations have
initial tooth discoloration.15-18 Many whitening toothpastes con- supported state regulations that restrict the practice of pro-
tain polishing or chemical agents to improve tooth appearance viding bleaching services to only dentists or other qualified
by removing extrinsic stains through gentle polishing, chem- dental staff under the direct supervision of a dentist.49-51 The
ically chelating, or other nonbleaching action.10,19 Carbamide use of over-the-counter whitening products remains exempt
peroxide is the most commonly used active ingredient in from such regulation. Legislation defining the scope of practice
dentist-dispensed tooth-bleaching products for home-use.10,20 by non-dentists offering whitening treatment varies from state
Side effects from bleaching vital and nonvital teeth have to state and should be examined when these services are
been documented. It should be noted that most of the research being provided.50-52
on bleaching has been performed on adult patients, with only
a small amount of published bleaching research using child or Policy statement
adolescent patients.2,4,8,14,17,21-24 The more common side effects Teeth whitening procedures that have been shown to be safe
associated with bleaching vital teeth are tooth sensitivity and may be beneficial for children and adolescents. Although the
tissue irritation. Tooth sensitivity associated with vital bleach- use of whitening agents can improve dental esthetics and en-
ing may be due to permeation of enamel and dentin by hydro- hance a person’s self-esteem, proper treatment planning with
gen peroxide and a subsequent mild, transient inflammatory objectives should be conducted prior to engaging in any
response.25-27 Hydrogen peroxide is a highly reactive substance bleaching protocol. Use of whitening agents should follow
which can cause damage to oral hard and soft tissues when the safety and efficacy standards as defined by clinical research
used at high concentrations and an extended period of time.28,29 and best practice. Bleaching by young patients should be
Between eight and 66 percent of patients experience post- supervised by an adult and under the guidance of a dentist.
bleaching sensitivity, most often during the early stages of The American Academy of Pediatric Dentistry encourages:
treatment.7,10,14,17,21,24 Overtreatment has been shown to harm • the judicious use of bleaching for vital and nonvital
tooth structure, which is of particular concern when bleaching teeth.
products are used excessively by overzealous teens and young • patients to consult their dentists to determine appro-
adults.29-31 Tissue irritation, in most cases, results from an ill- priate methods for and the timing of dental whitening
fitting tray rather than the bleaching agents and resolves once within the context of an individualized, comprehensive,
a more accurately fitted tray is used.32 Both sensitivity and tissue and sequenced treatment plan.
irritation usually are temporary and cease with the discontinu- • dental professionals and consumers to consider side effects
ance of treatment.6,7,14,17,19,21,24,33,34 Additional risks may include when contemplating dental bleaching for child and
erosion, mineral degradation, pulpal damage, and increased adolescent patients.
marginal leakage of existing restorations.14,35 When used • further research of dental whitening agents in children.
correctly, however, teeth bleaching has been proven to be safe
and causes no irreversible tooth structure damage.29 The American Academy of Pediatric Dentistry discourages
Internal bleaching for non-vital endodontically treated teeth full-arch cosmetic bleaching for patients in the mixed denti-
in young patients can be performed in the same way as for tion and primary dentition.
adults.29 The more common side effect from internal bleaching
of nonvital teeth is external root resorption.36-39 With external References
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Dent 2011;35(3):289-94. 52. American Dental Education Association State Update.
44. Palo RM, Valera MC, Camargo SE, et al. Peroxide Federal court upholds Georgia Board of Dentistry policy
penetration from the pulp chamber to the external root on teeth whitening. Available at: “https://www.adea.org/
surface after internal bleaching. Am J Dent 2010;23(3): Blog.aspx?id=36111&blogid=20132”. Accessed March
171-4.
45. Firat E, Ercan E, Gurgan S, Yucel OO, Cakir FY, Berker
®
citation.org/778lfyF0T”)
E. The effect of bleaching systems on the gingiva and
the levels of IL-1 Beta and IL-10 in gingival crevicular
fluid. Oper Dent 2011;36(6):572-80. Erratum in Oper
Dent 2012;37(1):108.

ORAL HEALTH POLICIES: USE OF LASERS
Policy on the Use of Lasers for Pediatric Dental

Patients
2017 the use of lasers for pediatric dental patients. The Reference
Purpose of energy that are delivered in a beam of unique wavelength

The American Academy of Pediatric Dentistry (AAPD) that is measured in nanometers.4 The wavelength of a dental
recognizes the judicious use of lasers as a beneficial instrument laser is the determining factor of the level to which the laser
in providing dental restorative and soft tissue procedures for energy is absorbed by the intended tissue. Target tissues
infants, children, and adolescents, including those with differ in their affinity for specific wavelengths of laser energy
special health care needs. This policy is intended to inform depending on the presence of the chromophore or the laser-
and educate dental professionals on the fundamentals, types, absorbing elements of the tissue.4-6 Oral hard and soft tissues
diagnostic and clinical applications, benefits, and limitations have a distinct affinity for absorbing laser energy of a specific
of laser use in pediatric dentistry. wavelength. For this reason, selecting a specific laser unit
depends on the target tissue the practitioner wishes to treat.
Methods The primary effect of a laser within target tissues is photo-
This policy was developed by the Council on Clinical Affairs thermal.7 When the temperature of the target tissue containing
and adopted in 2013. It is based on a review of current dental water is raised above 100 degrees Celsius, vaporization of the
and medical literature related to the use of lasers. This docu- water occurs, resulting in soft tissue ablation.1 Since soft tissue
ment included database searches using the terms: laser is made up of a high percentage of water, excision of soft
dentistry, dental lasers, laser pediatric dentistry, laser soft tissue tissue initiates at this temperature. Hard tissue composed of
treatments, and laser restorative dentistry. Articles were hydroxyapatite crystals and minerals are not ablated at this
evaluated by title and/or abstract and relevance to pediatric temperature, but the water component is vaporized and the
dental care. Expert and/or consensus opinion by experienced resulting steam expands and then disperses the encompassing
researchers and clinicians also was considered. material into small particles.6 Laser operating parameters such
as power, frequency, emission mode, thermal relaxation time,
Background and air and water coolant used affect the clinical abilities of a
Medicine began integrating lasers in the mid 1970s for soft laser. Additionally, the delivery system of laser unit as well as
tissue procedures. Oral and maxillofacial surgeons incorpo- the tissue concentration of the chromophore greatly influence
rated the carbon dioxide (CO2) laser into practice for removal the laser tissue interactions.
of oral lesions in the 1980s.1,2 The first laser specifically for Various types of lasers have been used in dentistry. Clinical
dental use was a neodymium-yttrium-aluminum-garnet applications of the lasers commonly used in pediatric dentistry
(Nd:YAG) laser, developed in 1987 and approved by the U.S. are listed in the Table.
Food and Drug Administration in 1990.3 Since then, laser
technology has advanced significantly. The use of lasers is con- Laser safety
tributing to many areas of dentistry including periodontics, Laser plume, a mixture of gases as well as debris, is generated
pediatrics, endodontics, oral surgery, restorative dentistry and during the use of lasers. When using dental lasers, it is im-
dental hygiene, cosmetic dental whitening, and management perative that the doctor and auxiliaries adhere to infection
of temporomandibular joint pain to name a few. control protocol and utilize high-speed suction as the vaporized
aerosol may contain infective tissue particles.2,8 The practitioner
Laser basics should exercise good clinical judgment when providing soft
While a detailed description of how lasers work is beyond tissue treatment of viral lesions in immunocompromised
the scope of this document, it is important to understand the
basics of laser physics prior to selecting a laser for dental treat-
ment. The term laser is an acronym for light amplification by ABBREVIATIONS
stimulated emission of radiation. Lasers are classified by the AAPD: American Academy Pediatric Dentistry. Nd:YAG: Neodymium-
active medium that is used to create the laser energy. Within yttrium-aluminum-garnet.
a laser, an active medium is stimulated to produce photons

patients, as the potential risk of disease transmission from soft tissue treatments, wound healing can occur more rapidly
laser-generated aerosol exists.9,10 To prevent viral transmission, with less post-operative discomfort and a reduced need for
palliative pharmacological therapies may be more acceptable analgesics.6,11-13 Little to no local anesthesia is required for
and appropriate in this group of patients. Reflected or scat- most soft-tissue treatments.6,12-14 Reduced operator chair time
tered laser beams may be hazardous to unprotected skin or has been observed when soft tissue procedures have been
eyes. Wavelength-specific protective eyewear should be completed using lasers.12,13 Lasers demonstrate decontami-
provided and consistently worn at all times by the dental team, nating and bacteriocidal properties on tissues, requiring less
patient, and other observers in attendance during laser use.2 prescribing of antibiotics post-operatively. 6,12,13 Lasers can
Many states have well defined laser safety regulations and provide relief from the pain and inflammation associated with
practitioners should contact their specific state boards to aphthous ulcers and herpetic lesions without pharmacological
obtain this information. intervention.5,12,13
Lasers can remove caries effectively with minimal involve-
Lasers in pediatric dentistry ment of surrounding tooth structure because caries-affected
One of the benefits of laser use in pediatric dentistry is the tissue has a higher water content than healthy tissue. 11 The
selective and precise interaction with diseased tissues.2 Less noise and vibration of the conventional high-speed dental
thermal necrosis of adjacent tissues is produced with lasers handpiece has been postulated as stimulating discomfort,
than with electrosurgical instruments. 11 During soft tissue pain, and anxiety for the pediatric patient during restorative
procedures, hemostasis can be obtained without the need for procedures.6,15-17 The non-contact of erbium lasers with hard
sutures in most cases.2,12 With the benefit of hemostasis during tissue eliminates the vibratory effects of the conventional
Table. LASER BASICS IN PEDIATRIC DENTISTRY

Laser type Wavelength Applications
Diode 450 - 655 nm 1. Laser fluorescence – diagnostic applications, detection of occlusal caries, detecting calculus
in periodontal pockets, detection of dysplastic cells during oral cancer screening
Diode 810 - 980 nm 1. Soft tissue ablation – gingival contouring for esthetic purposes, frenectomy, gingivectomy,
operculectomy
2. Photobiomodulation – proliferation of fibroblasts and enhancing the healing of oral lesions
(mucositis) or surgical wounds
3. Periodontal procedures – laser bacterial reduction, elimination of necrotic epithelial tissue
during regenerative periodontal surgeries
4. Whitening
Er, Cr:YSGG* 2,780 nm 1. Hard tissue procedures – enamel etching, caries removal and cavity preparation in enamel
and dentin
2. Osseous tissue procedures – bone ablation
3. Soft tissue ablation – gingival contouring for esthetic purposes, frenectomy, givectomy,
operculectomy
4. Endodontic therapy – pulp cap, pulpotomy, pulpectomy, root canal preparation
5. Periodontal procedures – laser bacterial reduction, elimination of necrotic epithelial tissue
during regenerative periodontal surgeries
6. Treatment of oral ulcerative lesions
Er:YAG** 2,940 nm 1. Hard tissue procedures – caries removal and cavity preparation in enamel and dentin
2. Endodontic therapy – root canal preparation
CO2† 9,300 nm 1. Hard tissue procedures – caries removal and cavity preparation in enamel and dentin
2. Osseous tissue procedures – bone ablation
3. Soft tissue procedures – incision, excision, vaporization, coagulation and hemostasis
CO2 10,600 nm 1. Soft tissue ablation – gingival contouring for esthetic purposes, frenectomy, gingivectomy
2. Treatment of oral ulcerative lesions
3. Periodontal procedures – elimination of necrotic epithelial tissue during regenerative
periodontal surgeries
* Er, Cr:YSGG – erbium, chromium, yttrium, scandium, gallium, garnet. ** Er:YAG – erbium, yttrium, aluminium, garnet. † CO2: Carbon dioxide.

high-speed handpiece allowing tooth preparations to be 5. Green J, Weiss A, Stern A. Lasers and radiofrequency
comfortable and less anxiety provoking for children and devices in dentistry. Dent Clin North Am 2011;55(3):
adolescents.6,15,17 Nd:YAG and erbium lasers have been shown 585-97.
to have an analgesic effect on hard tissues, eliminating in- 6. Martens LC. Laser physics and review of laser applica-
jections and the use of local anesthesia during tooth tions in dentistry for children. Eur Arch Paediatr Dent
preparations.6,15,18-20 2011;12(2):61-7.
7. White JM, Goodis HE, Kudler JJ, Tran KT. Thermal
Limitations of lasers in pediatric dentistry laser effects on intraoral soft tissue, teeth and bone in
There are some disadvantages of laser use in pediatric den- vitro. Third International Congress on Lasers in Den-
tistry. Since different wavelengths are necessary for various tistry. Salt Lake City, Utah: University of Utah Printing
soft and hard tissue procedures, the practitioner may need Services; 1992:189-90.
more than one laser.2 Laser use requires additional training 8. Piccone PJ. Dental laser safety. Dent Clin North Am
and education for the various clinical applications and types 2004;48(4):795-807.
of lasers.2,13,15,18 High start up costs are required to purchase 9. Parker S. Laser regulation and safety in general dental
the equipment, implement the technology, and invest in the practice. Br Dent J 2007;202(9):523-32.
required education and training.2,13 Most dental instruments 10. Garden JM, O’Bannon MK, Bakus AD, Olson C. Viral
are both side and end-cutting. When using lasers, modifica- disease transmitted by laser-generated plume (aerosol).
tions in clinical technique along with additional preparation Arch Dermatol 2002;138(10):1303-7.
with high-speed dental handpieces may be required to finish 11. Coluzzi DJ. Fundamentals of lasers in dentistry: Basic
tooth preparations.2,15 There are a variety of resources, such as science, tissue interaction and instrumentation. J Laser
the Academy of Laser Dentistry, available to assist dentists in Dent 2008;16(Spec Issue):4-10.
the training and education for safe and effective use of lasers. 12. Boj JR, Poirer C, Hernandez M, et al. Review: Laser soft
tissue treatments for paediatric dental patients. Eur Arch
Policy statement Paediatr Dent 2011;12(2):100-5.
The AAPD: 13. Olivi G, Genovese MD, Caprioglio C. Evidence-based
• Recognizes the use of lasers as an alternative and com- dentistry on laser paediatric dentistry: Review and out-
plementary method of providing soft and hard tissue look. Eur J Paediatr Dent 2009;10(1):29-40.
dental procedures for infants, children, adolescents, 14. Convissar RA, Goldstein EE. An overview of lasers in
and persons with special health care needs. dentistry. Gen Dent 2003;51(5):436-40.
• Advocates the dental professional receive additional 15. Olivi G, Genovese MD. Laser restorative dentistry in
didactic and experiential education and training on children and adolescents. Eur Arch Paediatr Dent 2011;
the use of lasers before applying this technology on 12(2):68-78.
pediatric dental patients. 16. Takamori K, Furukama H, Morikawa Y, et al. Basic
• Encourages dental professionals to research, implement, study on vibrations during tooth preparations caused by
and utilize the appropriate laser specific and optimal highspeed drilling and Er:YAG laser irradiation. Lasers
for the indicated procedure. Surg Med 2003;32(1):25-31.
• Endorses use of protective eyewear specific for laser 17. Tanboga I, Eren F, Altinok B, et al. The effect of low
wavelengths during treatment for the dental team, level laser therapy on pain during cavity preparation with
patient, and observers. laser in children. Eur Arch Paediatr Dent 2011;12(2):
93-5.
References 18. van As G. Erbium lasers in dentistry. Dent Clin North
1. Frame JW. Carbon dioxide laser surgery for benign oral Am 2004;48(4):1017-59.
lesions. Br Dent J 1985;158(4):125-8. 19. Matsumoto K, Hossain M, Hossain MM, et al. Clinical
2. Coluzzi DJ. Lasers in dentistry. Compend Contin Educ assessment of Er,Cr:YSGG laser applications for caries
Dent 2005;26(6A Suppl):429-35. removal and cavity preparation in children. Med Laser
3. Myers TD, Myers ED, Stone RM. First soft tissue study Appl 2002;20(1):17-21.
utilizing a pulsed Nd:YAG dental laser. Northwest Dent 20. Den Besten PK, White JM, Pelino JEP, et al. The safety
1989;68(2):14-7. and effectiveness of an Er:YAG laser for caries removal
4. Fasbinder DJ. Dental laser technology. Compend Contin and cavity preparation in children. Med Laser Appl 2001;
Educ Dent 2008;29(8):452-9. 16(3):215-22.

ORAL HEALTH POLICIES: SLEEP APNEA
Policy on Obstructive Sleep Apnea (OSA )

2016 obstructive sleep apnea (OSA). The Reference Manual of Pediatric
2020:119-21.
Purpose person from reaching deep, restful sleep. For this reason,
The American Academy of Pediatric Dentistry (AAPD) children with untreated OSA may be inappropriately diag-
recognizes that obstructive sleep apnea (OSA) occurs in the nosed as having ADHD.2
pediatric population. Undiagnosed and/or untreated OSA is OSA differs from central sleep apnea. Central sleep apnea
associated with cardiovascular complications, impaired growth (CSA) is less common and occurs when the brain fails to
(including failure to thrive), learning problems, and/or transmit signals to the muscles of respiration.4 The most
behavioral problems. In order to reduce such complications, common cause of CSA is congestive heart failure or stroke,
AAPD encourages healthcare professionals to routinely screen high altitude, and medication use; however, premature infants
their patients for increased risk for OSA and to facilitate also may be predisposed to CSA.3
medical referral when indicated. Symptoms of OSA include:1
• excessive daytime sleepiness.
Methods • loud snoring three or more nights per week.
This policy was developed by the Council on Clinical Affairs, • episodes of breathing cessation witnessed by another
and is based on a review of current dental and medical person.
literature pertaining to obstructive sleep apnea including a • abrupt awakenings accompanied by shortness of breath.
®
search with PubMed /MEDLINE using the terms: sleep apnea
and dentistry, obstructive sleep apnea and dentistry, obstructive
• awakening with dry mouth or sore throat.
• morning headache.
sleep apnea and attention-deficit hyperactivity disorder • difficulty staying asleep.
(ADHD), sleep disordered breathing; fields: all; limits: within • attention problems.
the last ten years, humans, all children zero to 18 years, • mouth breathing.
English, clinical trials, and literature reviews. The search re- • sweating.
turned 36 articles. The reviewers agreed upon the inclusion of • restlessness.
15 articles that met the defined criteria. When data did not • waking up a lot.
appear sufficient or were inconclusive, policies were based
upon expert and/or consensus opinion by experience researchers Signs of untreated sleep apnea in school-aged children
and clinicians. may include bed wetting and poor school performance due to
misdiagnosed ADHD, aggressive behavior, or developmental
Background delay.1 Rare sequelae of untreated OSA include brain damage,
Pediatric OSA is a disorder of breathing characterized by pro- seizures, coma, and cardiac complications.1-3 These children
longed, partial upper airway obstruction and or intermittent/ also may experience impaired growth.1,2
complete obstruction (obstructive apnea) that disrupts normal
ventilation during sleep and normal sleep patterns.1 OSA Etiology of OSA
affects approximately 18 million people in the United States Patients with certain anatomic anomalies, craniofacial anom-
and is a common form of sleep-disordered breathing. The con- alies, neuromuscular diseases, or Down syndrome are at
dition exists in one to five percent of children and can occur increased risk for development of obstructive sleep apnea.5
at any age, but may be most common in children ages two to Anatomic anomalies may include hypertrophic tonsils and
seven.2 Adult criteria for OSA may be used for patients aged adenoids, choanal atresia, respiratory tissue thickening (e.g.,
13-18 years.3 Early diagnosis and treatment of OSA may caused by disease such as polysaccharidosis, achondroplasia),
decrease morbidity. However, diagnosis frequently is delayed.1 or obesity.2 Neuromuscular disorders with a component of
Obstructive sleep apnea occurs when the muscles in the hypotonia (e.g., cerebral palsy, myotonic dystrophies, other
back of the throat relax, causing the airway to narrow on inspi-
ration. This, in turn, may lower the oxygen level in the blood.
ABBREVIATIONS
This decreased oxygen is sensed by the brain, which then
AAPD: American Academy Pediatric Dentistry. ADHD: Attention-
wakes the individual to facilitate breathing. This disruption in deficit hyperactivity disorder. CSA: Central sleep apnea. OSA:
breathing may occur multiple times per hour all night long.1 Obstructive sleep apnea. RPE: Rapid maxillary/palatal expansion.
Ultimately, these cycles of awakening prohibit the apneic

myopathies) predispose children to OSA.1 Additionally, infants etiology. Non-surgical options include treatment of nasal
with gastroesophageal reflux disease may be at risk for OSA allergies1, continuous positive airway pressure (CPAP), weight
due to upper airway edema or laryngospasm. Exposure to envi- reduction, and changes in sleep hygiene. Previously, three
ronmental tobacco smoke also has been associated with OSA.3 types of oral appliances commonly were used for treatment of
Midface deficiency, with or without micrognathia, may sleep-related breathing: mandibular advancing devices, tongue
predispose some children with craniofacial abnormalities to retaining devices, and palatal lift appliances.11 Although some
development of OSA.1,2 Certain surgical procedures (e.g., studies have advocated the use of non-surgical interventions
pharyngeal flaps to correct velopharyngeal insufficiency) in such as rapid maxillary/palatal expansion (RPE) or a modified
these patients also may contribute to OSA.3 monobloc appliance,2,12 these studies had small sample sizes.12
As functional intraoral appliances alter the position and/or
Diagnosis of OSA growth of the maxilla or mandible, a complete orthodontic
Pediatric dentists are in a unique position to be able to iden- assessment including records should be completed. It is ad-
tify patients at greatest risk. Adenotonsillar hypertrophy6 and vised that the dentist work with the physician to determine
obesity are major risk factors for OSA in otherwise healthy if adjunctive options (e.g., RPE, orthodontic treatment) are
children. With a history and careful clinical examination at advised as part of a multidisciplinary treatment effort. If a
each dental visit, pediatric dentists may identify signs and dentist decides to treat OSA with an intraoral appliance, it is
symptoms that may raise a concern for OSA. Assessment of strongly encouraged that the patient be reassessed throughout
tonsillar hypertrophy6 and percentage of airway obstruction by treatment for symptoms of OSA to determine if the treatment
the Friedman Tongue Classification system7 may be done as is working.1
part of the routine intraoral examination. The most common surgical option for treatment of OSA
Multiple screening tools are available for adult sleep apnea is adenotonsillectomy.14 Other surgical options include uvulo-
(e.g., STOP-BANG questionnaire8, Kushida Index9). How- palatopharyngoplasty, ablation, revision of previous posterior
ever, inclusion of sleep questions on the health history form pharyngeal flap surgery, distraction osteogenesis, or trache-
may further help identify patients at risk. Such questions ostomy.2
might include:
• does your child snore loudly when sleeping? Complications of untreated OSA
• does your child have trouble breathing while sleeping? In addition to the comorbidities listed previously (i.e., car-
• does your child stop breathing during sleep? diovascular problems, impaired growth, learning problems,
• does your child occasionally wet the bed at night? behavioral problems), untreated OSA in combination with
• is your child hard to wake up in the morning? insulin resistance and obesity in a child sets the stage for heart
• does your child complain of headaches in the morning? disease and endocrinopathies.
• does your child tend to breathe through his/her Pediatric dentists who perform sedation and surgical pro-
mouth during the day? cedures in patients with OSA should be aware that these
• have you or the teacher commented your child appears patients are more likely to experience perioperative and post-
sleepy during the day? operative breathing complications.15
• does your child fall asleep quickly?
Policy statement
If a patient is suspected of being at risk for OSA, a referral The AAPD recognizes that there may be consequences of
to the appropriate medical doctors (e.g., otolaryngologist, untreated OSA. Therefore, the AAPD encourages health care
pulmonologist, sleep medicine physician) is advised. Then, a professionals to:
clinical examination in addition to polysomnography (sleep • screen patients for snoring and sleep-related breathing
study) will either confirm or deny the diagnosis.10 The Amer- disorders.
ican Academy of Pediatrics recommends polysomnography be • screen patient for OSA.
performed in children/adolescents with snoring and signs/ • assess the tonsillar pillar area for hypertrophy.
symptoms of OSA.1 A positive diagnosis of OSA likely will • assess tongue positioning as it may contribute to
be made by a sleep physician in the presence of signs/ obstruction.
symptoms concurrent with at least one predominantly • recognize obesity may contribute to OSA.
obstructive respiratory event, mixed apnea, or hypopnea per • refer to an appropriate medical provider (e.g., otolar-
hour of sleep or a pattern of obstructive hypoventilation yngologist, sleep medicine physician, pulmonologist)
with hypercapnia for at least 25 percent of total sleep time for diagnosis and treatment of any patient suspected
during the polysomnography.3 of having OSA.
• consider non-surgical intraoral appliances only after
Treatment of OSA a complete orthodontic/craniofacial assessment of
Treatment for OSA may be accomplished with either non- the patient’s growth and development as part of a
surgical or surgical options, depending on its severity and multi-disciplinary approach.

References 10. Polysomnography Task Force, American Sleep Disorders

1. American Academy of Pediatrics. Clinical practice guide- Association Standards of Practice Committee. Practice
line on the diagnosis and management of childhood parameters for the indications for polysomnography and
obstructive sleep apnea syndrome. Pediatrics 2012;130 related procedures. Sleep 1997;20(6):402-22.
(3):576-684. 11. Hoffstein V. Review of oral appliances for treatment of
2. Padmanabhan V, Kavitha PR, Hedge AM. Sleep disor- sleep-disordered breathing. Sleep Breath 2007;11(1):
dered breathing in children—A review and the role of 1-22.
the pediatric dentist. J Clin Ped Dent 2010;35(1):15-21. 12. Capua M, Ahmadi N, Shapiro C. Overview of obstruc-
3. American Academy of Sleep Medicine. International tive sleep apnea in children: Exploring the role of dentist
Classification of Sleep Disorders, 3rd ed. Darien, Ill.: in diagnosis and treatment. J Can Dent Assoc 2009;75
American Academy of Sleep Medicine; 2014:63-8. (4):285-9.
4. Malhotra A, Owens RL. What is central sleep apnea? 13. Cozza P, Polimen A, Ballanti F. A modified monoblock
Respir Care 2010;55(9):1168-78. for the treatment of obstructive sleep apnoea in paediatric
5. Atkinson M. Sleep, snoring, and acute life-threatening patients. Eur J Orthod 2004;26(5):523-30.
events. Arch Dis Child Edu Pract Ed 2010;95(6):190-3. 14. Baldasarri CM, Mitchell RB, Schubert C, Rudnick EF.
6. Chan J, Edman JC, Koltai PH. Obstructive sleep apnea Pediatric obstructive sleep apnea and quality of life: A
in children. Am Fam Physician 2004;69(5):1147-54. meta-analysis. Otolaryn Head Neck Surg 2008;38(3):
7. Friedman M, Hamilton C, Samuelson C, Lundgren M, 265-73.
Pott T. Diagnostic value of the Friedman tongue posi- 15. American Society of Anesthesiologists Task Force on
tion and Mallampati classification for obstructive sleep Perioperative Management of patients with obstructive
apnea: A meta-analysis. Otolaryngol Head Neck Surg sleep apnea. Practice guidelines for the perioperative
2013;148(4):540-7. management of patients with obstructive sleep apnea:
8. Barsh LI. The recognition and management of sleep- an updated report by the American Society of Anesthe-
breathing disorders: A mandate for dentistry. Sleep Breath siologists Task Force on Perioperative Management of
2009;13(1):1-2. patients with obstructive sleep apnea. Anesthesia 2014;
9. Jauhar S, Orcharson R, Banham SW, Livingston E, 120(2):268-86.
Sherriff A, Lyons MF. The Kushida Index as a screening
tool for obstructive sleep apnoea-hypopnoea syndrome.
Brit Dent J 2012;212E2:1-3.

ORAL HEALTH POLICIES: ACUTE PAIN MANAGEMENT
Policy on Acute Pediatric Dental Pain Management

2017 acute pediatric dental pain management. The Reference Manual of
Purpose developmental disabilities is more challenging to assess

The American Academy of Pediatric Dentistry (AAPD) accurately and may require utilization of scales that rely on
recognizes that children vary greatly in their cognitive and observations such as vocalization, facial expressions, and body
emotional development, medical conditions, and responses movements.3-5
to pain and interventions. Infants, children, adolescents, and In addition to documenting pain severity, it is important
those with special health care needs can and do experience to assess pain onset, pattern, location, and quality; aggravating
pain, and the majority of pain in the dental setting can be and relieving factors; previous treatment and its effect; and
prevented or substantially relieved. The AAPD further recog- barriers to assessment.6 When assessing pain in a child, the
nizes that there are many therapeutics available to treat pain patient’s psychological status should be considered. The dentist
with varying dosages and/or regimens. Recent concerns have also should account for the intensity and duration of pain
developed about toxicities associated with codeine. that may be perceived from a given dental procedure.7,8 Pain
management may range from non-pharmacologic modalities
Methods to pharmacological treatment. Nonpharmacologic therapy
This policy was developed by the Council on Clinical Affairs includes maintaining a calm environment, encouraging deep
and adopted in 2012. This document is an update of the breathing, and employing guided imagery, distraction, play
previous version and is based on a review of current dental therapy, and tell-show-do. 9 Pharmacologic therapy may
and medical literature pertaining to pediatric pain manage- consist of administration of topical and local anesthesia, anal-
®
ment including a search with PubMed /MEDLINE using
the terms: pediatric dental pain management, pediatric pain
gesic medications, and/or mild, moderate, or deep sedation
regimens.9,10
management, pediatric postoperative pain management, The extent of treatment affects post-operative pain. It
pediatric analgesic overdose; fields: all; limits: within the last has been reported that 95 percent of children undergoing full
ten years, humans, all children zero to 18 years, English, clin- mouth dental rehabilitation, regardless of extent of treatment,
ical trials, and literature reviews. The search returned 3,388 report pain of moderate intensity. 8 Pain scores usually are
articles. The reviewers agreed upon the inclusion of 12 new highest immediately postoperatively while the patient is in
documents that met the defined criteria. Nine additional the post-anesthesia recovery unit. 8 Due to analgesics and/or
documents were retained from the previous version of the local anesthetics administered intra-operatively during dental
policy for historical purposes. When data did not appear rehabilitation, some patients may be delayed in their pain
sufficient or were inconclusive, information included in response and report greater intensity of pain at home follow-
this police was based upon expert and/or consensus opinion ing the procedures. Patients who had extractions, as well as
by experienced researchers and clinicians those who had 12 or more dental procedures, were more
likely to experience pain at home.8
Background The selection of an appropriate analgesic depends on the
Pain assessment is an integral component of the dental history individual patient, the extent of treatment, the duration of
and comprehensive evaluation. When symptoms or signs of the procedure, psychological factors, and the patient’s medical
orofacial/dental pain are evident, a detailed pain assessment history. Physiologic factors such as bleeding disorders, liver
should be conducted and documented in the patient’s record. problems, and kidney problems should be given particular
This assessment helps the dentist to derive a clinical diagno- attention since some analgesics may promote bleeding. 11 If
sis, develop a prioritized treatment plan, and better estimate moderate to severe pain is considered likely, an analgesic
analgesic requirements for the patient. should be administered on a regular schedule during the first
Pain is difficult to measure due to its subjectivity, especially 36 to 48 hours to create stable plasma levels of analgesics and
in children,1,2 and often relies on the report of parents. There decrease the chance of breakthrough pain.11,12
are several pain scale indicators that can be used with children,
including the Faces Pain Scale and the Wong-Baker FACES
Pain Rating Scale.1,2 The method of assessing pain selected by
® ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. FDA: U.S. Food
the practitioner must accurately reflect pain intensity. Pain and Drug Administration. NSAIDs: Nonsteroidal anti-inflammatory
experienced by children with special health care needs or drugs.

Treatment of postoperative pain may include opioid anal- Administration (FDA) are available and could be considered
gesics and non-opioid analgesics. Since most cases of postoper- to identify both ultra-rapid and poor metabolizers of codeine
ative pain include an inflammatory component, nonsteroidal and other opioid analgesics.18 Tramadol and, to a lesser extent,
anti-inflammatory drugs (NSAIDs) are considered first line hydrocodone and oxycodone also are influenced by CYP2D6
agents in the treatment of acute mild to moderate postoper- activity, and ultra-rapid metabolizers may have an increased
ative pain.11 Aspirin-containing analgesics are contraindicated risk of toxicity.20 In April, 2017, the FDA issued a warning to
for pediatric pain management in most situations because, if restrict the use of codeine and tramadol medicines in children
administered during a viral illness, the potential exists for a and breastfeeding mothers.21 Morphine and non-opioid alter-
serious condition known as Reye syndrome.13 Acetaminophen natives are not influenced by CYP2D6 metabolism.20
lacks anti-inflammatory properties but can be a non-opioid
alternative when NSAIDs are contraindicated.11 Acetaminophen Policy statement
is found as a single agent and also in combination with other The AAPD recognizes that children experience pain and ex-
drugs. Overdose of acetaminophen is a potential pediatric hibit variability in the expression of pain and that inadequate
emergency, and the maximum daily dose should be observed, pain management may have significant physical and psy-
especially when combination medications are used.14 Alternat- chological consequences for the patient. Therefore, the AAPD
ing administration of ibuprofen and acetaminophen is another encourages health care professionals to:
strategy for pain management in children.6,15 Acetaminophen • recognize, assess, and document symptoms of pain
or NSAIDs also can be administered rectally or intravenously, in the patient’s record.
which may be practical in some settings (e.g., an operating • consider preoperative, intraoperative, and postoperative
room).13 pain management options.
Practitioners may be hesitant to prescribe opioid analgesics • use non-pharmacologic and pharmacologic strategies
for pediatric patients for fear of addiction. Because opioid use to reduce pain experience.
for dental pain should be of short duration, physical depend- • utilize drug formularies in order to accurately prescribe
ence is unlikely and its use should be considered.12 Opioid medications for the management of pain.
analgesics are effective for moderate to severe postoperative • choose agents compatible with the patient’s medical
pain, but have potential for adverse effects (e.g., nausea, emesis, history.
constipation, sedation, respiratory depression) and diversion.15-17 • comprehend the consequences, morbidities, and toxi-
Parental anxiety about postoperative pain and potential adverse cities associated with the use of specific therapeutics.
effects of pain medications may influence administration of • consider non-opioid analgesics as first line agents for
analgesics at home.6,7 Strategies that educate parents about pain management.
anticipated postoperative discomfort and the benefits of pain • consider simultaneous use of analgesics with different
medication have been associated with reduced reports of pain mechanisms of action to optimize pain management.
in pediatric patients.7 Parental education, expectation manage- Combining opioid analgesics with NSAIDs or aceta-
ment, and effective use of non-opioid analgesics are keys in minophen for moderate to severe pain may decrease
reducing adverse effects of opioid analgesics. Opioid analgesics overall opioid consumption.
such as hydrocodone and oxycodone are often combined with • support additional clinical research to extend the un-
acetaminophen. Concomitant or alternating opioid adminis- derstanding of the risks and benefits of both opioid and
tration with ibuprofen can reduce opioid consumption. nonopioid alternatives for orally-administered, effective
Codeine, a prodrug that is metabolized into morphine in agents for acute and chronic pain.19
the liver, has been removed from many hospital formularies
due to safety concerns. 18-20 Individual response to codeine The AAPD supports the FDA’s April, 2017 safety commu-
ranges from high sensitivity to no effect at all due to genetic nication 21 which states that codeine and tramadol are
variability.19,20 A genetic polymorphism of the liver cytochrome contraindicated for treatment of pain in children younger than
enzyme CYP2D6 causes some patients to be ultra-rapid meta- 12 years.
bolizers of codeine.18 Ultimately, these patients convert codeine
into high levels of morphine very quickly. For this reason, References
postoperative use of codeine has been associated with undesir- 1. Barrêtto EPR, Ferreira EF, Pordeus IA. Evaluation of
able consequences including death in infants and children.18-20 toothache severity in children using a visual analog scale
Another variant of CYP2D may cause patients to be poor of faces. Pediatr Dent 2004;26(6):485-91.
metabolizers of codeine and, consequently, under-respond to 2. Jain A, Yeluri R, Munshi AK. Measurement and assess-
the opioid.20 Repeated doses of codeine-containing analgesics ment of pain in children. J Clin Pediatr Dent 2012;37
in these patients fail to result in adequate analgesia since (20):125-36.
codeine is not effectively broken down into the active meta-
bolite morphine.20 Tests cleared by the U.S. Food and Drug References continued on the next page.

3. Institute of Medicine. Relieving Pain in America: A Blue- 14. American Association of Poison Control Centers. Practice
print for Transforming Prevention, Care, Education, and guideline: Acetaminophen poisoning: An evidence-based
Research. Washington, D.C.: The National Academies consensus guideline for out-of-hospital management.
Press. Available at: “http://www.uspainfoundation.org/ Clin Toxicol 2006;44(1):1-18.
wp-content/uploads/2016/01/IOM-Full-Report.pdf ” 15. Liu C, Ulualp SO. Outcomes of an alternating ibuprofen
Accessed December 10, 2016. (Archived by WebCite
at: “http://www.webcitation.org/6mefMJ1cd”)
® and acetaminophen regimen for pain relief after tonsil-
lectomy in children. Ann Otol Rhinol Laryngol 2015;
4. Feldt KS. The checklist of nonverbal pain indicators 124(10):777-81.
(CNPI). Pain Manag Nurs 2000;1(1):13-21. 16. Yaksh TL, Wallace MS. Opioids, analgesia and pain
5. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The management. In: Brunton LL, Chabner BA, Knollmann
FLACC: A behavioral scale for scoring postoperative BS, eds. Goodman and Gilman’s the Pharmacological
pain in young children. Pediatr Nurs 1997;23(3):293-7. Basis of Therapeutics. 12th ed. New York, N.Y.: McGraw-
6. Chou R, Gordon DB, de Leon-Cassola OA, et al. Guide- Hill; 2010:481-526.
lines on the management of postoperative pain. Manage- 17. Dionne R, Moore P. Opioid prescribing in dentistry:
ment of postoperative pain: A clinical practice guideline Keys for safe and proper usage. Compend 2016;37(1):
from the American Pain Society, American Society of 21-34.
Regional Anesthesia and Pain Medicine, American Society 18. U.S. Food and Drug Administration. Drug Safety Com-
of Anesthesiologists’ Committee on Regional Anesthesia, munication: Safety review update of codeine use in
Executive Committee, and Administrative Counsel. J Pain children; New boxed warning and contraindication on
2016;17(2):131-57. use after tonsillectomy and/or adenoidectomy. Available
7. American Academy of Pediatrics, American Pain Society. at: “http://www.fda.gov/drugs/drugsafety/ucm339112.
The assessment and management of acute pain in infants, htm”. Accessed December 10, 2016. (Archived by Web-
children and adolescents. Pediatrics 2001;108(3):793-7.
8. Needleman HL, Harpayat S, Wu S, Allred EN, Berde C.
®
Cite at: “http://www.webcitation.org/6mee873Qm”)
19. Tobias JD, Green TP, Coté CJ, American Academy of
Postoperative pain and other sequelae of dental rehabilita- Pediatrics Section on Anesthesiology and Pain Medicine,
tions performed on children under general anesthesia. American Academy of Pediatrics Committee on Drugs.
Pediatr Dent 2008;30(2):111-21. Codeine: Time to say “No”. Pediatrics 2016;138(4):
9. Lee GY, Yamada J, Kyololo O, Shorkey A, Stevens B. e20162396. Available at: “http://pediatrics.aappublica
Pediatric clinical practice guidelines for acute procedural tions.org/content/pediatrics/early/2016/09/15/peds.
pain: A systematic review. Pediatr 2014;133(3):500-15. 2016-2396.full.pdf ”. Accessed July 1, 2017. (Archived by
10. American Academy of Pediatric Dentistry. Use of local
anesthesia for pediatric dental patients. Pediatr Dent
®
WebCite at: “http://www.webcitation.org/6sjq8xisf ”)
20. Crews KR, Gaediek A, Dunnenberger HM. Clinical
2017;39(6):266-72. Pharmacogenetics Implementation Consortium –
11. Becker DE. Pain management: Part 1: Managing acute guidelines for cytochrome p450 2D6 genotype and
and postoperative dental pain. Anesth Prog 2010;57(2): codeine therapy: 2014 update. Clin Pharmacol Ther
67-79. 2014;95(4):376-82.
12. Sutters KA, Miaskowsk C, Holdridge-Zeuner D, et al. 21. U.S. Food and Drug Administration. Drug Safety Com-
A randomized clinical trial of the efficacy of scheduled munication: FDA restricts use of prescription codeine
dosing of acetaminophen and hydrocodone for the pain and cough medicines and tramadol pain medicines
management of postoperative pain in children after in children; recommends against use in breastfeeding
tonsillectomy. Clin J Pain 2010;26(2):95-103. women. Available at: “https://www.fda.gov/Drugs/
13. Ruest C, Anderson A. Management of acute pediatric DrugSafety/ucm549679.htm”. Accessed May 26, 2017.
pain in the emergency department. Curr Opin Pediatr
2016;28(3):298-304.
®
org/6sjqTDBYs”)

ORAL HEALTH POLICIES: MINIMIZING HEALTH HAZARDS WITH NITROUS OXIDE
Policy on Minimizing Occupational Health Hazards

Associated with Nitrous Oxide
2018 minimizing occupational health hazards associated with nitrous
oxide. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
Purpose exposure to nitrous.12 NIOSH has recommended that the

The American Academy of Pediatric Dentistry (AAPD) exhaust ventilation of N2O from the patient’s mask be main-
recognizes that exposure to ambient nitrous oxide (N2O) may tained at an air flow rate of 45 liters per minute and vented
be an occupational health hazard for dental personnel and outside the building away from fresh air intakes.1,5 However,
encourages practitioners to take all precautions to minimize scavenging at this rate has been shown to reduce the level
associated risks. of psychosedation achieved with N2O inhalation.13 Where
possible, outdoor air should be used for dental operatory
Methods ventilation.1,14 Supply and exhaust vents should be well
This policy was developed by the Clinical Affairs Committee separated to allow good mixing and prevent short-circuiting.1
and adopted in 1987, and was revised by the Council of Clin- Female dental staff frequently (i.e., three or more days a week)
ical Affairs. This document is a revision of the previous version, exposed to nitrous oxide have been found to have no elevated
revised in 2013. The update used electronic database and hand risk of spontaneous abortion in offices using appropriate
searches of articles in the medical and dental literature using scavenging systems.15,16
the following parameters: terms: nitrous oxide, occupational Patient selection is an important consideration in reducing
exposure, AND dentistry; fields: all; limits: within the last 10 ambient N2O levels.7 Patients who are unwilling or unable
years, English. Additionally, guidelines and recommendations to tolerate the nasal hood and those with medical conditions
from the National Institute for Occupational Safety and Health (e.g., obstructive respiratory diseases, emotional disturbances,
(NIOSH) were reviewed.1-2 Expert opinions and best current drug dependencies) that contraindicate the use of N2O should
practices were relied upon when sufficient scientific data were be managed by other behavior guidance techniques.7 In the
not available. dental environment, patient behaviors such as talking, crying,
and moving have been shown to result in significant increases
Background in baseline ambient N2O levels despite the use of the mask-
Effects of occupational exposure to ambient N2O are uncer- type scavenging systems.17,18 Utilization of titrated nitrous con-
tain, especially since the introduction of methods to scavenge centration levels in relation to procedure difficulty should be
N2O and ventilate operatories.3 As of 2008, there were no considered. Nitrous can be discontinued once adequate anes-
definitive studies linking general health problems and thesia is achieved,19 or decreased levels can be maintained during
reproductive difficulties among dental personnel to chronic easier procedures and increased for stimulating procedures.5
exposure to scavenged ambient N2O.3 A maximum safe level The use of scavenging systems alone cannot lower the
of ambient N2O in the dental environment has not been ambient N2O levels to the recommended standards.8,17,20 Use
determined.4-6 of supplemental measures, such as high-volume dental suction
Reduction of ambient N2O through system maintenance, placed in proximity to the dental operative site, has been
scavenging, ventilation, use of the minimal effective dose, and shown to reduce ambient N2O levels significantly.17,21 Diligent
patient management is important to maintaining the lowest use of the above practices in the pediatric dental environment
practical levels in the dental environment.1,2,7 Frequent and has allowed for the reduction of ambient N2O to the levels
regular inspection and maintenance of the N2O delivery recommended by NIOSH.21,22 Measurement of N2O levels
system, together with the use of a scavenging system, can rein the dental operatory can be helpful in determining the type
duce ambient N2O significantly.8 Using a well-fitted mask and extent of remediation necessary to decrease occupational
and an appropriate suction strength via the scavenging system exposure.
will minimize leakage, reducing ambient N2O levels.8,9 The use
of a double-mask patient delivery system also has been shown
to be more effective than a single-mask system in the removal ABBREVIATIONS
of waste nitrous oxide.10,11 The combined use of the double AAPD: American Academy Pediatric Dentistry. N20: Nitrous oxide.
mask system and scavenging systems with a high evacuation NIOSH: National Institute for Occupational Safety and Health.
flow rate have been demonstrated to decrease occupational

ORAL HEALTH POLICIES: MINIMIZING HEALTH HAZARDS WITH NITROUS OXIDE
Policy statement 9. Crouch KG, Johnston OE. Nitrous oxide control in the
The AAPD encourages dentists and dental auxiliaries to dental operatory: Auxiliary exhaust and mask leakage,
maintain the lowest practical levels of N2O in the dental en- design, and scavenging flow rate as factors. Am Ind Hyg
vironment while using N2O. Adherence to the recommenda- Assoc J 1996;57(3):272-8.
tions below can help minimize occupational exposure to N2O. 10. Chrysikopoulou A, Matheson P, Miles M, Shey Z, Houpt
• Educate dental personnel on minimizaing occupational M. Effectiveness of two nitrous oxide scavenging nasal
exposure to and potential abuse of nitrous oxide. hoods during routine pediatric dental treatment. Ped
• Use scavenging systems that remove N2O during Dent 2006;28(3):242-7.
patient’s exhalation. 11. Freilich MM, Alexander L, Sandor GKB, Judd P. Effec-
• Ensure that exhaust systems adequately vent scavenged tiveness of 2 scavenger mask systems for reducing expo-
air and gases to the outside of the building and away sure to nitrous oxide in a hospital-based pediatric dental
from fresh air intake vents. clinic: A pilot study. J Can Dent Assoc 2007;73(7):
• Use, where possible, outdoor air for dental operatory 615-615d. Available at: “http://www.cda-adc.ca/jcda/vol
ventilation. -73/issue-7/615.pdf ”. Accessed October 1, 2018.
• Implement careful, regular inspection and mainte- 12. Messeri A, Amore E, Dugheri S, et al. Occupational expo-
nance of the nitrous oxide/oxygen delivery equipment. sure to nitrous oxide during procedural pain control in
• Carefully consider patient selection criteria (i.e., indi- children: A comparison of different inhalation techniques
cations and contraindications) prior to administering and scavaging systems. Pediatr Anaesth 2016;26(1):
N2O. 919-25.
• Select a properly-fitted mask size for each patient. 13. Primosch R, McLellan M, Jerrell G, Venezie R. Effect of
• During administration, visually monitor the patient scavenging on the psychomotor and cognitive function
and titrate the flow/percentage to the minimal effec- of subjects sedated with nitrous oxide and oxygen in-
tive dose of N2O. halation. Pediatr Dent 1997;19(8):480-3.
• Encourage patients to minimize talking and mouth 14. Centers for Disease Control and Prevention. Control of
breathing during N2O administration. nitrous oxide in dental operatories. 2014. Available at:
• Use high volume dental suction when possible during “https://www.cdc.gov/niosh/docs/hazardcontrol/hc3.
N2O administration. html”. Accessed May 31, 2018. Archived by WebCite ®
• Administer 100 percent oxygen to the patient for at at: “http://www.webcitation.org/71NbEfa74”)
least five minutes after terminating nitrous oxide use 15. Rowland AS, Baird DD, Shore DL, et al. Reduced
to replace the N2O in the gas delivery system. fertility among women employed as dental assistants
exposed to high levels of nitrous oxide. N Engl J Med
References 1992;327(14):993-7.
1. National Institute of Occupational Safety and Health. 16. Rowland AS, Baird DD, Shore DL, Weinberg CR, Savitz
Control of nitrous oxide in dental operatories. Appl DA, Wilcox AJ. Nitrous oxide and spontaneous abortion
Occup Environ Hyg 1999;14(4):218-20. in female dental assistants. Am J Epidemiol 1995;141
2. National Institute of Occupational Safety and Health. (6):531-7.
Controlling exposures of nitrous oxide during anesthetic 17. Henry RJ, Primosch RE, Courts FJ. The effects of various
administration. Cincinnati, Ohio: National Institute of dental procedures and patient behaviors upon nitrous
Occupational Safety and Health; 1994. DHHS/NIOSH oxide scavenger effectiveness. Pediatr Dent 1992;14(1):
Publication No. 94-100. 19-25.
3. Sanders RD, Weimann J, Maze M. Biologic effects of 18. Crouch KG, McGlothin JD, Johnston OE. A long-term
nitrous oxide. Anesthesiology 2008;109(4):707-22. study of the development of N2O controls at a pediatric
4. Howard WR. Nitrous oxide in the dental environment: dental facility. Am Ind Hyg Assoc J 2000;61(5):753-6.
Assessing the risk and reducing the exposure. J Am Dent 19. Guelmann M, Brackett R, Beavers N, Primosch RE.
Assoc 1997;128(3):356-60. Effect of continuous versus interrupted administration of
5. American Dental Association Council on Scientific nitrous oxide-oxygen inhalation on behavior of anxious
Affairs, American Dental Association Council on Dental pediatric dental patients: A pilot study. J Clin Pediatr
Practice. Nitrous oxide in the dental office. J Am Dent Dent 2012;37(1):77-82.
Assoc 1997;128(3):364-5. 20. Gilchrist F, Whitters CJ, Cairns AM, Simpson M, Hosey
6. Donaldson D, Meechan JG. The hazards of chronic ex- MT. Exposure to nitrous oxide in a paediatric dental
posure to nitrous oxide: An update. Br Dent J 1995;178 unit. Int J Paediatr Dent 2007;17(2):116-22.
(3):95-100. 21. Henry RJ, Borganelli GN. High-volume aspiration as a
7. American Academy of Pediatric Dentistry. Use of nitrous supplemental scavenging method for reducing ambient
oxide for pediatric dental patients. Pediatr Dent 2018;40 nitrous oxide levels in the operatory: A laboratory study.
(6):281-6. Int J Paediatr Dent 1995;5(2):157-61.
8. Rademaker AM, McGlothlin JD, Moenning E, Bagnoli 22. Borganelli GN, Primosch RE, Henry RJ. Operatory
M, Carlson G, Griffin C. Evaluation of two nitrous ventilation and scavenger evacuation rate influence on
oxide scavenging systems using infrared thermography to ambient nitrous oxide levels. J Dent Res 1993;72(9):
visualize and control emissions. J Am Dent Assoc 2009; 1275-8.
140(2):190-9.

ORAL HEALTH POLICIES: HOSPITALIZATION AND OPERATING ROOM ACCESS
Policy on Hospitalization and Operating Room

Access for Oral Care of Infants, Children, Adolescents,
and Individuals with Special Health Care Needs
2020 hospitalization and operating room access for oral care of infants,
children, adolescents, and Individuals with special health care needs.
Purpose programs. Pediatric dentists are, by virtue of training and ex-

The American Academy of Pediatric Dentistry (AAPD) perience, qualified to recognize the indications for such an
advocates, when indicated, hospitalization and equal access to approach and to render such care.10,11
operating room facilities for oral care of infants, children, Pediatric dentists occasionally have experienced difficulty
adolescents, and individuals with special health care needs. The in gaining an equal opportunity to schedule operating room
AAPD recognizes that barriers to hospital oral care for patients time, postponement/delay of non-emergency oral care, and
who require treatment in that setting need to be addressed. economic credentialing. Economic credentialing (i.e., the use
of economic criteria not related to quality of care or profes-
Methods sional competency) to determine qualifications for granting/
This policy was developed by the Dental Care Committee and renewing an individual’s clinical staff membership or privileges
adopted in 19891 and was last revised by the Council of should be opposed.12 The AAPD and the ADA urge hospital
®
Clinical Affairs in 20152. A PubMed /MEDLINE search was
performed using the terms: access for dental/oral care in hos-
insurance carriers to include hospitalization benefits for dental
treatment in both private and public insurance programs so
pitals, operating room access for dental/oral care, and access that the resources of a hospital are available to patients whose
to hospital dentistry; fields: all; limits: within the last 10 condition in the judgment of the dentist warrants treatment
years, humans, English, birth through age 18. Additionally, in the operating room.13,14
websites for the American Medical Association, American Den- Hospital governing boards and medical staffs are interested
tal Association (ADA), AAPD, American Dental Association in improving the quality and efficiency of patient care. Deci-
Commission on Dental Accreditation, and Centers for Disease sions regarding hospital privileges should be based upon the
Control and Prevention were reviewed. training, experience, and demonstrated competence of candi-
dates, taking into consideration the availability of facilities
Background and the overall medical needs of the community, the hospital,
Pediatric dentists treat patients who present special challenges and especially the patients. Privileges should not be based on
related to their age, behavior, medical status, developmental numbers of patients admitted to the facility or the patient’s
disabilities, or special needs. Caries, periodontal diseases, and economic or insurance status.15
other oral conditions, if left untreated, can lead to pain, infec-
tion, and loss of function.3-5 These undesirable outcomes can Policy statement
adversely affect learning, communication, nutrition, and other The AAPD shall work with all concerned medical and dental
activities necessary for normal growth and development.5-8 colleagues and organizations to remove barriers to hospital and
Many medical conditions (e.g., hematological, oncological) operating room access for oral care for patients best treated in
are exacerbated by the presence of oral maladies and disease. those settings. The AAPD affirms that hospitals or outpatient
To address these challenges and to provide the treatment needs settings providing surgical treatment should not discriminate
effectively, pediatric dentists have developed and employ a against pediatric dental patients requiring care under general
variety of management techniques, including accessing anes- anesthesia. Such patients and their care providers need access
thesia services and/or the provision of oral health care in a
hospital setting with or without general anesthesia.9 Some
children with particular compromising medical conditions ABBREVIATIONS
may only be able to receive their dental treatment safely in a AAPD: American Academy Pediatric Dentistry. ADA: American
hospital setting. Hospital dentistry is an integral part of the Dental Association.
curriculum of all accredited advanced pediatric dental training

ORAL HEALTH POLICIES: HOSPITALIZATION AND OPERATING ROOM ACCESS
to these facilities. The dental patient, as with any other 10. American Dental Association Commission on Dental
patient, should have the right to be seen in a timely manner. Accreditation. Accreditation standards for advanced spe-
Evidence has demonstrated dental treatment under general cialty education programs in pediatric dentistry: Hospital
anesthesia in the operating room is a necessity, as well as an dentistry. Chicago, Ill.: American Dental Association;
important component of comprehensive care, to assure opti- 2018:31-3.
mal health for many, especially those considered high-risk.16-18 11. Forsyth AR, Seminario AL, Scott J, Berg J, Ivanova I,
Lee H. General anesthesia time for pediatric dental cases.
References Pediatr Dent 2012;34(5):129-35.
1. American Academy of Pediatric Dentistry Dental Care 12. American Medical Association. Policy H-230.975 Econo-
Committee. Hospitalization for dental care of infants mic credentialing. 2017. American Medical Association
and children. May, 1989. Orlando, Fla.: American PolicyFinder. Available at: “https://policysearch.ama-assn.
Academy of Pediatric Dentistry; 1989. org/policyfinder/detail/230.975?uri=%2FAMADoc%2FH
2. American Academy of Pediatric Dentistry. Hospitali- OD.xml-0-1606.xml”. Accessed August 6, 2020.
zation and operating room access for oral care of infants, 13. American Academy of Pediatric Dentistry. Policy on
children, adolescents, and persons with special health care model dental benefits for infants, children, adolescents,
needs. Pediatr Dent 2015;37(special issue):88-9. and individuals with special health care needs. The
3. Acs G, Pretzer S, Foley M, Ng MW. Perceived outcomes Reference Manual of Pediatric Dentistry. Chicago, Ill.:
and parental satisfaction following dental rehabilitation American Academy of Pediatric Dentistry; 2020:131-4.
under general anesthesia. Pediatr Dent 2001;23(5): 14. American Dental Association. Economic credentialing
419-23. (Trans.1993:692). Hospitals. In: Current Policies.
4. American Academy of Pediatric Dentistry. Definition Adopted 1954-2019. Chicago, Ill.: American Dental
of dental neglect. The Reference Manual of Pediatric Association; 2019:120. Available at: “http://www.ada.
Dentistry. Chicago, Ill.: American Academy of Pediatric org/~/media/ADA/Member%20Center/Members/current
Dentistry; 2020:16. _policies.pdf ”. Accessed August 6, 2020.
5. Low W, Tan S, Schwartz S. The effect of severe caries on 15. American Medical Association. Code of Medical Ethics
the quality of life in young children. Pediatr Dent 1999; Opinion 9.5.2. Staff privileges. Ethics. American Medical
21(6):325-6. Association. November 14, 2016. Available at: “https://
6. Edelstein B, Yoder K. The child in context of the fam- www.ama-assn.org/delivering-care/ethics/staff-privileges”.
ily, community and society. In: Dean JA, ed. McDonald Accessed August 6, 2020.
and Avery’s Dentistry for the Child and Adolescent. 10th 16. Chi DL, Momany ET, Neff J, et al. Impact of chronic
ed. St. Louis, Mo: Elsevier; 2016:645-62. condition status and severity on dental utilization for
7. Thomas CW, Primosch RE. Changes in incremental Iowa Medicaid-enrolled children. Pediatr Anes 2010;20
weight and well-being of children with rampant caries (9):856-65.
following complete dental rehabilitation. Pediatr Dent 17. Chang J, Patton LL, Kim HY. Impact of dental treatment
2002;24(2):109-13. under general anesthesia on the oral health-related quality
8. American Academy of Pediatric Dentistry. Definition of of life of adolescents and adults with special needs. Eur
dental disability. The Reference Manual of Pediatric J Oral Sci 2014;122(6):363-71.
Dentistry. Chicago, Ill.: American Academy of Pediatric 18. Park JS, Anthonappa RP, Yawary R, King NM, Martens
Dentistry; 2020:17. LC. Oral health-related quality of life changes in children
9. Velan E, Sheller B. Providing dental treatment for chil- following dental treatment under general anesthesia: A
dren in a hospital setting. Dent Clin North Am 2013; meta-analysis. Clin Oral Investig 2018;22(8):2809-18.
57(1):163-73.

ORAL HEALTH POLICIES: HOSPITAL STAFF MEMBERSHIP
Policy on Hospital Staff Membership

2020 hospital staff membership. The Reference Manual of Pediatric
2020:129-30.
Purpose issued by healthcare accreditation organizations such as The

The American Academy of Pediatric Dentistry recognizes that Joint Commission.4 Standards for dental services are integrated
dentists have an opportunity to play a significant role intimately and inseparably within the overall hospital
within a hospital. Staff membership is necessary to provide organizational structure and, therefore, are stringently subject
comprehensive, consultative, and/or emergency dental services to the standards established by these commissions.
for infants, children, adolescents, and persons with special As per the American Medical Association’s Code of Medical
health care needs within the hospital setting. Ethics, “the purpose of medical staff privileging is to improve
the quality and efficiency of patient care in the hospital”,
Methods while selection should be based on a candidate’s training,
This policy was developed by the Hospital Guidelines for experience, competence, availability, and the overall medical
Pediatric Dentistry Ad Hoc Committee and adopted in 1977.1 needs of the community. 5 Select organizations associate a
This document by the Council on Clinical Affairs is a dentist’s economic performance and other monetary param-
revision of the previous version2, last revised in 2015. The eters with their ability to establish privileges. Facilities may
update included an electronic search using the terms: hospital employ economic credentialing (i.e., using economic criteria
medical staff and Joint Commission, AND dentistry; fields: not related to quality of care or professional competency) to
all; limits: within the last 10 years, humans, English. protect their financial interests. The use of economic creden-
tialing to determine qualifications for granting/renewing an
Background individual’s clinical staff membership or privilege is strongly
Pediatric dentists contribute in multiple ways as members of opposed by the American Medical Association.6 Economic
the hospital staff. Most commonly, the pediatric dentist can credentialing may present in a variety of forms such as pro-
provide comprehensive oral health care services to patients viding individuals with contract exclusivity, profiling practice
within an operating room setting. Additionally, the pediatric habits, or identifying potential conflicts of interest. Objective
dentist can provide consultative and emergency services.3 credentialing decisions should always be guided by concern
Team (e.g., cleft lip/palate, hemophilia) evaluations of patients for the welfare and best interest of the patient.
often require dental input, and certain medical protocols
(e.g., hematopoietic cell transplantation) require an oral Policy statement
examination. Beyond patient services, a pediatric dentist may The American Academy of Pediatric Dentistry:
participate within the hospital’s organizational structure • encourages the participation of pediatric dentists on
through committee memberships of either clinical or admin- hospital medical/dental staffs. Beyond having the
istrative purpose. A pediatric dentist can partner with medical capability to provide valuable services to patients,
colleagues in self-development through hospital-sponsored the pediatric dentist can be an effective, contributing
continuing medical education. member to the hospital through consultative services,
Pediatric dentists seeking hospital staff membership must educational opportunities, leadership initiatives, and
contact the medical staff office at an area hospital. Board committee membership.
certification or candidacy routinely is required for hospital • recognizes the American Dental Association as a cor-
staff membership. Following a credentialing process and porate member of The Joint Commission and further
appointment to a medical staff, a pediatric dentist must recognizes the standards for hospital governance, as
accept and fulfill certain responsibilities. Among them are established by The Joint Commission.
patient care within the limits of approved clinical privileges, • encourages hospital member pediatric dentists to
possible participation in emergency department on-call ro- maintain strict adherence to the rules and regulations
tations, timely completion of medical records, and compliance of the medical/dental staff and the policies and
with the rules and regulations of the medical/dental staff and procedures of the hospital.
the policies and procedures of the hospital. • is opposed to the use of economic credentialing to
Although hospitals and medical/dental staffs have some determine qualifications for granting/renewing a
individual latitude, the standards for all hospital services are practitioner’s clinical staff membership or privileges.

ORAL HEALTH POLICIES: HOSPITAL STAFF MEMBERSHIP
References 5. American Medical Association. Staff privileges. American

1. American Academy of Pedodontics. Hospital guidelines Medical Association Code of Medical Ethics Opinion
for pediatric dentistry. Chicago, Ill.: American Academy 9.5.2. November 14, 2016. Available at: “https://www.
of Pedodontics; 1977. ama-assn.org/delivering-care/ethics/staff-privileges”.
2. American Academy of Pediatric Dentistry. Policy on Accessed August 6, 2020.
hospital staff membership. Pediatr Dent 2015;37(special 6. American Medical Association. Policy H-230.975 Eco-
issue):90-1. nomic credentialing. 2017. American Medical Association
3. Weddell JA, Jones JE. Hospital dental services for chil- PolicyFinder. Available at: “https://policysearch.ama-assn.
dren and the use of general anesthesia. In: Dean JA, org/policyfinder/detail/230.975?uri=%2FAMADoc%2FH
ed. McDonald and Avery’s Dentistry for the Child and OD.xml-0-1606.xml”. Accessed August 6, 2020.
Adolescent. 10th ed. St. Louis, Mo.: Elsevier; 2016:328.
4. The Joint Commission. Electronic Accreditation and
Certification. Available at: “https://www.jointcommission.
org/accreditation-and-certification/”. Accessed August
6, 2020.

ORAL HEALTH POLICIES: MODEL DENTAL BENEFITS
Policy on Model Dental Benefits for Infants,

Children, Adolescents, and Individuals with
Special Health Care Needs
2017 model dental benefits for infants, children, adolescents, and indi-
viduals with special Health care needs. The Reference Manual of
Purpose and those proceedings are published in a special issue of

The American Academy of Pediatric Dentistry (AAPD) believes Pediatric Dentistry. Those documents2-8 as well as clinical
that all infants, children, adolescents, and individuals with practice guidelines from other organizations with recognized
special health care needs must have access to comprehensive professional expertise and stature7-16 serve as the basis for the
preventive and therapeutic oral health care benefits that recommendations below. Such recommendations ideally are
contribute to their optimal health and well-being. This policy evidence based but, in the absence of conclusive evidence,
is intended to assist policy makers, third-party payors, and may rely on expert opinion and clinical observations.
consumer groups/benefits purchasers to make informed deci-
sions about the appropriateness of oral health care services for Policy statement
these patient populations. The AAPD encourages all policy makers and third-party pay-
ors to consult the AAPD in the development of benefit plans
Methods that best serve the oral health interests of infants, children,
This policy was developed by the Council on Dental Benefit adolescents, and individuals with special health care needs.
Programs and Council on Clinical Affairs and adopted in These model services are predicated on establishment of a
2008. This policy is based upon a review of the AAPD’s dental home, defined as the ongoing relationship between the
systematically-developed oral health policies and clinical dentist (i.e., the primary oral health care provider) and the
practice guidelines as well as clinical practice guidelines that patient, inclusive of all aspects of oral health care, starting
have been developed by other professional organizations and no later than 12 months of age.17
endorsed by the AAPD. Value of services is an important consideration, and the
AAPD encourages all stakeholders to recognize that a least
Background expensive treatment is not necessarily the most beneficial or
The AAPD advocates optimal oral health and health care for cost effective plan in the long term for the patient’s oral
all infants, children, adolescents, and individuals with special health.
health care needs. Oral diseases are progressive and cumulative; The following services are essential components in health
ignoring oral health problems can lead to needless pain and benefit plans.
suffering, infection, loss of function, increased health care A. Preventive services:
costs, and lifelong consequences in educational, social, and 1. initial and periodic orofacial examination, including
occupational environments. A dental benefit plan should medical, dental and social histories, furnished in accord-
be actuarially sound and fiscally capable of delivering plan ance with the attached periodicity schedule2 or when
benefits without suppressing utilization rates or the delivery oral screenings by other health care providers indicate a
of services. When a benefits plan, whether for a commercial risk of caries or other dental or oral disease.
or government program, is not actuarially sound and ade- 2. education for the patient and the patient’s family on
quately underwritten, access and appropriate care under the measures that promote oral health as part of initial and
plan are placed at risk. When oral health care is not periodic well-child assessment.
accessible, the health implications, effects on quality of life,
and societal costs are enormous.1 The AAPD’s oral health
policies and clinical guidelines2 encourage the highest possible
level of care to children and patients with special health care ABBREVIATION
needs. The AAPD also sponsors a national consensus confer- AAPD: American Academy Pediatric Dentistry.
ence or symposium each year on pediatric oral health care

3. age-appropriate anticipatory guidance and counseling I. Drug prescription for preventive services, relief of pain, or
on non-nutritive habits, injury prevention, and tobacco treatment of infection or other conditions within the dentist’s
use/substance abuse. scope of practice.
4. application of topical fluoride at a frequency based upon
caries risk factors. J. Medically-necessary services for preventive and therapeutic
5. prescription of a high-concentration fluoridated tooth- care in patients with medical, physical, or behavioral condi-
paste for patients over six years old who are at moderate tions. These services include, but are not limited to, the care
to high caries risk. of hospitalized patients, sedation, and general anesthesia in
6. prescription of dietary fluoride supplement15 based upon outpatient or inpatient hospital facilities.
a child’s age and caries risk as well as fluoride level of
the water supply or supplies and other sources of dietary K. Behavior guidance services necessary for the provision of
fluoride. optimal therapeutic and preventive oral care to patients with
7. application of pit and fissure sealants on primary and medical, physical, or behavioral conditions. These services
permanent teeth based on caries risk factors, not patient may include both pharmacologic and non-pharmacologic
age.18 management techniques.
8. dental prophylactic services at a frequency based on
caries and periodontal risk factors. L. Consultative services provided by a pediatric dentist when
requested by a general practitioner or another dental specialist
B. Diagnostic procedures consistent with guidelines developed or medical care provider.
by organizations with recognized professional expertise and
stature, including radiographs in accordance with recommenda- References
tions by the American Academy of Oral and Maxillofacial 1. U.S. Department of Health and Human Services. Oral
Radiology, U.S. Food and Drug Administration and the health in America: A report of the Surgeon General–
American Dental Association.11,16,19 Executive summary. Rockville, Md.: U.S. Department
of Health and Human Services, National Institute of
C. Restorative and endodontic services to relieve pain, resolve Dental and Craniofacial Research, National Institutes of
infection, restore teeth, and maintain dental function and oral Health; 2000. Available at: “http://nidcr.nih.gov/Data
health. This would include interim therapeutic restorations, Statistics/SurgeonGeneral/Report/ExecutiveSummary.
a beneficial provisional technique in contemporary pediatric htm”. Accessed December 4, 2016. (Archived by Web-
restorative dentistry.2 ®
Cite at: "http://www.webcitation.org/6mW8vDmtm")
2. American Academy of Pediatric Dentistry. Reference
D. Orthodontic services including space maintenance and Manual. Chicago, Ill. Pediatr Dent 2017;39(6):1-504.
services to diagnose, prevent, intercept, and treat malocclu- Available at: “http://www.aapd.org/policies”. Accessed
sions, including management of children with cleft lip or July 5, 2017.
palate and/or congenital or developmental defects. These 3. American Academy of Pediatric Dentistry. Pediatric
services include, but are not limited to, initial appliance Dentistry Restorative Consensus Conference. Pediatr
construction and replacement of appliances as the child grows. Dent 2015;37(2):98-170.
4. American Academy of Pediatric Dentistry. Symposium
E. Dental and oral surgery including sedation/general on Behavior Guidance. Pediatr Dent 2014;36(2):98-160.
anesthesia and related medical services performed in an office, 5. American Academy of Pediatric Dentistry. Symposium
hospital, or ambulatory surgical care setting. on the Prevention of Oral Disease in Children and
Adolescents. Pediatr Dent 2006;28(2):96-198.
F. Periodontal services to manage gingivitis, periodontitis, and 6. American Academy of Pediatric Dentistry, American
other periodontal diseases or conditions in children. Association of Endodontists. Proceedings of the Joint
Symposium on Emerging Science in Pulp Therapy: New
G. Prosthodontic services, including implants with restorations Insights into Dilemmas and Controversies. November
to restore oral function. 2-3, 2007. Chicago, Ill. Pediatr Dent 2008;30(3):190-267.
7. American Academy of Pediatric Dentistry. Symposium
H. Diagnostic and therapeutic services related to the acute and on Trauma. November 14-15, 2008, Chicago, Ill. Pediatr
long-term management of orofacial trauma. When the injury Dent 2009;31(2):94-163.
involves a primary tooth, benefits should cover complications 8. American Academy of Pediatric Dentistry, American
for the developing succedaneous tooth. When the injury in- Association of Endodontists. Proceedings of the Joint
volves a permanent tooth, benefits should cover long-term Symposium: Contemporary Management of Traumatic
complications to the involved and adjacent or opposing teeth. Injuries to the Permanent Dentition. November, 2012,
Scottsdale, Ariz. Pediatr Dent 2013;35(2):102-90, 198.

9. American Association of Endodontists. Guide to Clinical 13. National Foundation for Ectodermal Dysplasias. Param-
Endodontics. 6th ed. Chicago, Ill.: American Association eters of Oral Health Care for Individuals Affected by
of Endodontists; 2013. Available at: “http://www.aae. Ectodermal Dysplasias. National Foundation for Ecto-
org/clinical-resources/aae-guide-to-clinical-endodontics. dermal Dysplasias. Mascoutah, Ill.; 2003. Revision 2015.
aspx”. Accessed December 4, 2016. (Archived by Web- Available at: “https://www.nfed.org/learn/library/
®
Cite at: “http://www.webcitation.org/6mW6Mb23m") parameters-dental-health-care/”. Accessed July 3, 2013.
10. American Academy of Periodontology. Periodontal Accessed December 4, 2016. (Archived by WebCite at: ®
diseases of children and adolescents. J Periodontol 2003; “http://www.webcitation.org/6mW8Wrq4U”)
74(11):1696-704. 14. Rozier RG, Adair S, Graham F, et al. Evidence-based
11. American Dental Association, U.S. Department of Health clinical recommendations on the prescription of dietary
and Human Services. Recommendations for Patient fluoride supplements for caries prevention: A report of
Selection and Limiting Radiation Exposure. Revised: the American Dental Association Council on Scientific
2012. Available at: “http://www.ada.org/~/media/ADA/ Affairs. J Am Dent Assoc 2010;141(12):1480-9.
Publications/ADA%20News/Files/Dental_Radiographic 15. Clark MB, Slayton RL, American Academy of Pediatrics
_Examinations_2012.pdf?la=en”. Accessed December 4, Clinical Report: Fluoride use for caries prevention in the
®
2016. (Archived by WebCite at: “http://www.web primary care setting. Pediatr 2014;134(3):626-33.
citation.org/6mW7ppEuF”) 16. Carter L, Geist J, Scarfe WC, et. al. American Academy
12. American Cleft Palate-Craniofacial Association. Parame- of Oral and Maxillofacial Radiology executive opinion
ters for Evaluation and Treatment of Patients with Cleft statement on performing and interpreting diagnostic
Lip/Palate or Other Craniofacial Anomalies. Chapel Hill, cone beam computed tomography. Oral Surg Oral Med
N.C.: The Maternal and Child Health Bureau, Title V, Oral Pathol Oral Radiol 2008;106(4):561-2.
Social Security Act, Health Resources and Services 17. American Academy of Pediatric Dentistry. Definition of
Administration, U.S. Public Health Service, DHHS; dental home. Pediatr Dent 2017;39(6):12.
November 2009. Grant # MCJ-425074. Available at: 18. Crall JJ, Donley, KJ. Dental sealants guidelines develop-
“http://www.acpa-cpf.org/uploads/site/Parameters_Rev_ ment 2002-2014. Pediatr Dent 2015;37(2):111-5.
2009.pdf ”. Accessed December 4, 2016. (Archived by 19. American Academy of Pediatric Dentistry. Prescribing
WebCite® at: “http://www.webcitation.org/6mW6yJcBj”) dental radiographs for infants, children, adolescents, and
individuals with special health care needs. Pediatr Dent
2017;39(6):205-7.
Recommended Dental Periodicity Schedule on the next page.

Recommended Dental Periodicity Schedule for Pediatric Oral Health Assessment,

Preventive Services, and Anticipatory Guidance /Counseling
Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are developing normally.
These recommendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from normal. The American
Academy of Pediatric Dentistry emphasizes the importance of very early professional intervention and the continuity of care based on the individualized needs of the
child. Refer to the text in the Recommendations on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Infants,
Children, and Adolescents ( http://www.aapd.org/policies/) for supporting information and references.
AGE
®
6 TO 12 MONTHS 12 TO 24 MONTHS 2 TO 6 YEARS 6 TO 12 YEARS 12 YEARS

AND OLDER
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ORAL HEALTH POLICIES: REIMBURSEMENT FOR MANAGEMENT OF SHCN
Policy on Third-Party Reimbursement for

Management of Patients with Special Health Care
Needs
2017 third-party reimbursement for management of patients with
special health care needs. The Reference Manual of Pediatric
2020:135-7.
Purpose were unable to obtain this service.3 This trend continued in

The American Academy of Pediatric Dentistry (AAPD) the more recent 2005 National Survey.4 These patients face a
recognizes that, because of improvements in medical care, the multitude of barriers in accessing dental care. These barriers
number of patients with special health care needs will continue may be either environmental/system-centered or non-
to grow. Many of the formerly acute and fatal diagnoses have environmental. 5 Environmental barriers to obtaining oral
become chronic and manageable conditions. These patients healthcare include difficulties in finding a dental office close
require a dental team with special knowledge and skills and to home that will accept the patient’s dental insurance and is
additional staff time to coordinate care and/or accommodate able to accommodate the patient’s unique needs, in addition
the patient’s unique circumstances. An increased appointment to the rising costs of healthcare. Non-environmental factors
length often is necessary in order to treat the patient in a safe, center around the patient: the patient is afraid of the dentist,
effective, and high-quality manner. Such customized services orally defensive, or unable to cooperate for the dentist. Addi-
have not been reimbursed by third-party payors. AAPD advo- tionally, the patient’s medical condition may complicate dental
cates reimbursement for measures that are necessary to manage treatment or the patient may have health care needs more
the patient’s unique healthcare needs within the dental home. urgent than dental care.5
Patients with special health care needs may require more
Methods provider time, particularly those with developmental disabil-
This policy was developed by the Council on Clinical Affairs, ities, complex health care issues, behavioral issues, and dental
and is a review of current dental and medical literature, sources fears.6 Many dentists often are unwilling to treat these indi-
of recognized professional expertise related to medical and viduals due to medical conditions, the additional time required
dental reimbursement, and industry publications. An electronic to obtain a medical history or medical consultations and
®
search was conducted using the PubMed /MEDLINE data-
base with the terms: special health care needs and access to
render treatment, poor reimbursement, and inadequate training
in treatment of patients with special health care needs. 7-10
care, special health care needs and reimbursement, disease Consequently, pediatric dentists provide a disproportionate
management and managed care, disease management and amount of care to this population, but U.S. pediatric dentists
insurance, disease management and reimbursement; fields: all; are too few in number to meet the need.11 While the AAPD
limits: within the last 20 years, humans, English, birth through has obtained federal funding for expansion and creation of
age 99. The search found 1375 articles. Papers for review were new pediatric dental residency positions, little has been done
chosen from this list and from the references within selected on the financial front by third-party payors.
articles. Financing and reimbursement of dental care have been cited
as common barriers for medically necessary oral health care
Background in the special needs population.5,12-14 Eliminating or reducing
About 18 percent (12.5 million) of U.S. children have special the effect of this barrier may have lasting positive effects on
health care needs, and numbers continue to rise.1 The AAPD oral health for patients with special health care needs. Patients
defines special needs as “any physical, developmental, mental, with significant health histories require additional appointment
sensory, behavioral, cognitive, or emotional impairment or
limiting condition that requires medical management, health
care intervention, and/or use of specialized services or pro- ABBREVIATIONS
grams.”2 The 2001 National Survey of Children with Special AAPD: American Academy Pediatric Dentistry. CPT: Current Proce-
Health Care Needs (CSHCN) determined the dental care was dural Terminology. CSHCN: Children with special health care needs.
the largest unmet need. More than eight percent of CSHCN

time to take a thorough history, as well as additional time for individuals in a dental home setting. Care coordination activities
medical consultation, documentation, and care coordina- for patients with SHCN that are more systematically proactive,
tion. Currently, there is a medical model that seeks to account rather than reactive, and allow for comprehensive manage-
for this increased time above the usual amount of time a ment could reduce hospitalizations and avoid emergency room
practitioner would take to treat a non-complex patient.15,16 In visits. Furthermore, reimbursement for the use of additional
the medical model, if the additional time that is spent is for personnel or advanced behavior management techniques could
counseling and/or coordination of care, then physicians are reduce the need for costly general anesthesia and facilitate the
allowed to bill for evaluation and management ([E/M]; Current delivery of medically necessary oral health care to which these
Procedural Terminology [CPT] codes 99201-99215) based patients are entitled. Therefore, the AAPD advocates that
on time. In doing this, physicians need to document the third-party payors and managed care organizations review their
following information: capitation policies to provide adequate reimbursement for care
• total time of the visit, coordination (CPT code D9992) and behavior management
• time or percent of the visit spent in counseling/coordi- (CPT code D9920).
nation of care, and
• nature of the counseling/coordination of care. References
Discussing referrals to other providers and ordering of tests 1. Newacheck, PW, McManus M, Fox HB, Hung YY, Halfon
meet the time criteria.16 N. Access to health care for children with special health
Adequate reimbursement for the care coordination code care needs. Pediatrics 2000;105(4 Pt 1):760-6.
(D9992)17 will more accurately identify patients with special 2. American Academy of Pediatric Dentistry. Definition of
health care needs and help alleviate the loss of income that special health care needs. Pediatr Dent 2017;39(6):16.
dentists experience while treating these individuals. Care 3. U.S. Department of Health and Human Service, Health
coordination offers the possibility of improving quality and Resources and Service Administration, Maternal and
controlling costs for patients with complex conditions.18 Child Health Bureau. The National Survey of Children
Many patients with special needs can be treated in the with Special Health Care Needs Chartbook 2001.
traditional clinical setting without the increased medical risk Rockville, Md.: U.S. Department of Health and Human
or additional cost of general anesthesia, but the provision of Service; 2004. Available at: “https://mchb.hrsa.gov/chscn
this care may take additional time and involve the use of /pages/toc.htm”. Accessed June 30, 2017. (Archived by
additional personnel or use of advanced behavior management
techniques. When physicians are faced with similar circum-
®
WebCite at: “http://www.webcitation.org/6sio1Qzu9”)
4. U.S. Department of Health and Human Service, Health
stances, they are able to use the prolonged service codes (CPT Resources and Service Administration, Maternal and
codes 99354 and 99356).16 In order to qualify for billing either Child Health Bureau. The National Survey of Children
code, the physician or other qualified healthcare professional with Special Health Care Needs Chartbook 2005-2006
must provide at least one hour of face-to-face patient contact, Summary Tables. Rockville, Md.: U.S. Department of
either outpatient or inpatient respectively, beyond the usual Health and Human Service; 2008. Available at: “https:
evaluation and management service. CPT codes 99355 and //www.cdc.gov/nchs/data/slaits/summary_tables_nscshcn
99357 may be used if the prolonged service is increased by an _0506.pdf ”. Accessed August 7, 2017. (Archived by
additional 30 minute increment.16 The behavior management
code (CDT code 9920) in Current Dental Terminology17 is most
®
WebCite at: “http://www.webcitation.org/6ta0sBiOn”)
5. Nelson LP, Getzin A, Graham D, et al. Unmet dental
similar to the prolonged service code. Reimbursement for the needs and barriers to care for children with significant
behavior management code could reduce the need for costly special health care needs. Pediatr Dent 2011;33(1):29-36.
general anesthesia and facilitate the delivery of medically 6. Hernandez PJR. Perspective of a parent and provider
necessary oral health care to which these patients are entitled. for children with special health care needs. Pediatr Dent
Payment reform via implementation and reimbursement of 2007;29(2):105-7.
these codes could allow the dental home to follow an impor- 7. Burtner AP, Jones JS, McNeal DR, Low DW. A survey
tant trend of the medical home. Care coordination activities of the availability of dental services to developmentally
could change from being mostly reactive to patients’ episodic disabled persons residing in the community. Spec Care
needs to being more systematically proactive and compre- Dent 1990;10(6):182-4.
hensive 19 thereby reducing hospitalizations and avoiding 8. Casamassimo PS, Seale NS, Ruehs K. General dentists’
emergency room visits.18 perceptions of educational and treatment issues affecting
access to care for children with special health care needs.
Policy statement J Dent Educ 2004;68(1):23-8.
The AAPD recognizes that the population of people with 9. Edelstein BL. Conceptual frameworks for understanding
special health care needs is increasing, and that additional system capacity in the care of people with special health
time and skills are necessary to provide optimal care to those care needs. Pediatr Dent 2007;29(2):108-16.

10. Ferguson FS, Berentsen B, Richardson PS. Dentists’ will- 16. American Medical Association. Current Procedural
ingness to provide care for patients with developmental Terminology Professional Edition: CPT: 2015. Chicago,
disabilities. Spec Care Dentist 1991;11(6):234-7. Ill.: American Medical Association; 2014.
11. Casamassimo PS. Children with special healthcare needs: 17. American Dental Association. CDT 2017: Dental Proce-
Patient, professional and systems issues. In: Proceedings dure Codes. Chicago, Ill.: American Dental Association;
of the Interfaces Project, 2002. Children’s Dental Health 2016.
Project, Washington, D.C. Available at: “http://www. 18. Goodell S, Bodenheimer T, Berry-Millet R. The Synthe-
oralhealthkansas.org/pdf/Casamassimo.pdf ”. Accessed sis Project. Care management of patients with complex
®
August 7, 2017. (Archived by WebCite at: “http://www. health care needs. Policy Brief No. 19. Robert Wood
webcitation.org/6ta10um2E”) Johnson Foundation. 2009. Available at: “http://www.
12. Rouleau T, Harrington A, Brennan M, et al. Receipt of rwjf.org/en/library/research/2009/12/care-management-of-
dental care and barriers encountered by persons with patients-with-complex-health-care-needs.html”. Accessed
disabilities. Spec Care Dentist 2011;31(2):63-7. ®
December 19, 2016. (Archived by WebCite at: “http://
13. da Fonseca MA, Hong C. Improving oral health for www.webcitation.org/6tkG3xTWl”)
individuals with special health care needs. Pediatr Dent 19. Van Cleave J, Boudreau AA, McAllister J, Cooley WC,
2007;29(2):98-104. Maxwell A, Kuhlthau K. Care coordination over time
14. Kastner T, American Academy of Pediatrics. Managed in medical homes for children with special health care
care and children with special healthcare needs. Clinical needs. Pediatr 2015;35(6):1018-26.
Report—Guidance for the clinician in rendering pedi-
atric care. Pediatr 2004;114(12):1696-8.
15. Dowling R. How physicians can get paid for time spent
with patients: Billing E/M codes based on time. Medical
Economics. July 24, 2014. Available at: “http://medical
economics.modernmedicine.com/medical-economics/
content/tags/billing/how-physicians-can-get-paid-time-
spent-patients?page=full”. Accessed October 12, 2016.
®
org/6sincJVqQ”)

ORAL HEALTH POLICIES: REIMBURSEMENT OF MEDICAL FEES — SEDATION / GA
Policy on Third-Party Reimbursement of Medical

Fees Related to Sedation/ General Anesthesia for
Delivery of Oral Health Care Services
2016 third-party reimbursement of medical fees related to sedation/
general anesthesia for delivery of oral health care needs. The
Purpose necessary. This determination appears to be based on incon-

The American Academy of Pediatric Dentistry (AAPD), to sistent criteria.9-11 For instance, medical policies often provide
ensure that all children have access to the full range of oral reimbursement for sedation/general anesthesia or facility fees
health delivery systems, advocates that if sedation or general related to myringotomy for a three-year-old child, but deny
anesthesia and related facility fees are payable benefits of a these benefits when related to treatment of dental disease and/
healthcare plan, these same benefits shall apply for the deliv- or infection for the same patient.
ery of oral health services. Dental rehabilitation of early childhood caries (ECC) has
shown a significant improvement in oral health-related quality
Methods of life (QOL) in children.4,12-21 Children undergoing compre-
This policy was developed by the Dental Care Committee, hensive dental treatment under general anesthesia exhibited
adopted in 1989, and last revised by the Council of Clinical improvement in several areas such as sleeping, eating, and
Affairs. This document is an update of the previous policy, pain.4,13-16 Parents reported their children to have a better per-
revised in 2011, and is based on a review of the current dental ceived QOL one to four weeks following dental rehabilitation
literature related to guidelines for sedation and general under general anesthesia.17 Dental treatment under general
anesthesia, as well as issues pertaining to medically-necessary anesthesia is associated with significant improvements in the
oral health care. The update included a PubMed /MEDLINE ®
search using the terms: general anesthesia/sedation costs, gen-
patient’s QOL and has been reported to have a positive impact
on the family’s quality of life.12 ADA Resolution 1989-546
eral anesthesia/sedation reimbursement, general anesthesia/ states that insurance companies should not deny benefits that
sedation insurance coverage, and general anesthesia/oral otherwise would be payable “solely on the basis of the pro-
health-related quality of life and limit: within the last 10 years fessional degree and licensure of the dentist or physician
as well as relevant articles from dental and medical literature. providing treatment, if that treatment is provided by a legally
The search returned 95 articles. The reviewers agreed upon the qualified dentist or physician operating within the scope of
inclusion of 24 articles that met the defined criteria. Relevant his or her training and licensure”.22
policies and guidelines of the AAPD and the American Dental A majority of states have enacted legislation requiring med-
Association (ADA) are included. Additionally, expert opinions ical insurers to reimburse for hospital charges associated with
and best current practices were relied upon when clinical provision of dental care for children in the operating room.5
evidence was not available. Such legislation has resulted in increased access to care, with
more children receiving services in an operating room setting
Background after enactment of legislation.23
For some infants, children, adolescents, and persons with
special health care needs, treatment under sedation/general Policy statement
anesthesia in a hospital, outpatient facility, or dental office or The AAPD encourages all policy makers and third party pay-
clinic represents the only viable method to deliver necessary ors to consult the AAPD in the development of benefit plans
oral health care.1-3 The patient’s age, dental needs, disabilities, that best serve the oral health interests of infants, children,
medical conditions, and/or acute situational anxiety may pre- adolescents, and individuals with special health care needs.
clude the patient from being treated safely in a traditional
outpatient setting.3-8 These patients may be denied access to
oral health care when insurance companies refuse to provide ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ADA: American Dental
reimbursement for sedation/general anesthesia and related facil-
Association. ECC: Early childhood caries. QOL: Quality of life.
ity services. Most denials cite the procedure as not medically

The AAPD strongly believes that the treating dentist de- palsy and a group of healthy pediatric patients. Med
termines the medical necessity for sedation/general anesthesia Oral Patol Oral Cir Bucal 2014;19(5):e490-4.
consistent with accepted guidelines on sedation and general 7. American Academy of Pediatric Dentistry. Guideline for
anesthesia.1,7 monitoring and management of pediatric patients during
The AAPD strongly encourages third-party payors to: and after sedation for diagnostic and therapeutic pro-
1. recognize that sedation or general anesthesia is necessary cedures. Pediatr Dent 2016;38(special issue):216-45.
to deliver compassionate, quality oral health care to some 8. American Academy of Pediatric Dentistry. Guideline on
infants, children, adolescents, and persons with special use of anesthesia personnel in administration of office-
health care needs. based deep sedation/general anesthesia to the pediatric
2. include sedation, general anesthesia, and related facility dental patient. Pediatr Dent 2016;38(special issue):
services as benefits of health insurance without discrim- 246-9.
ination between the medical or dental nature of the 9. White BA. The costs and consequences of neglected
procedure. medically necessary oral care [review]. Spec Care Dentist
3. end denial of reimbursement for sedation, general anes- 1995;15(5):180-6.
thesia, and facility costs related to the delivery of oral 10. Cameron CA, Litch CS, Liggett M, Heimberg S. Na-
health care. tional Alliance for Oral Health Consensus Conference
4. regularly consult the AAPD and the ADA with respect on Medically-Necessary Oral Health Care: Legal issues.
to the development of benefit plans that best serve the Spec Care Dentist 1995;15(5):192-200.
oral health interests of infants, children, adolescents, and 11. Crall J. Behavior management conference Panel II report
patients with special care needs.24 –Third party payor issues. Pediatr Dent 2004;26(2):171-4.
12. Jankauskiene B, Narbutaite J. Changes in oral health-
The AAPD encourages all states to enact general anesthe- related quality of life among children following dental
sia legislation that requires third party payors to reimburse for treatment under general anaesthesia. A systematic review.
facility and/or anesthesia costs associated with providing oral Stomatologija 2010;12(2):60-4.
health care for children. 13. Jankauskiene B, Virtanen JI, Kubilius R, Narbutaite J.
Oral health-related quality of life after dental general
References anaesthesia treatment among children: A follow-up study.
1. American Academy of Pediatric Dentistry. Definition of BMC Oral Health 2014;14(1):1-7.
medically-necessary care. Pediatr Dent 2016;38(special 14. Gaynor WN, Thomson WM. Changes in young chil-
issue):15. dren’s OHRQoL after dental treatment under general
2. American Academy of Pediatrics. Model contractual anaesthesia. Int J Paediatr Dent 2012;22(4):258-64.
language for medical necessity for children. Pediatr 2005; 15. Yawary R, Anthonappa RP, Ekambaram M, McGrath C,
116(1):261-2. Reaffirmed October 2011, Available at: King NM. Changes in the oral health-related quality of
“http://www.pediatrics.org/cgi/doi/10.1542/96 peds. life in children following comprehensive oral rehabilita-
2011-3210”. Accessed September 6, 2015. (Archived by tion under general anaesthesia. Int J Paediatr Dent 2016;
®
WebCite at: “http://www.webcitation.org/6fW67njQU”)
3. Glassman P, Caputo A, Dougherty N, et al. Special Care 16.
26(5):322-9.
Baghdadi ZD. Children’s oral health-related quality of
Dentistry Association consensus statement on sedation, life and associated factors: Midterm changes after dental
anesthesia, and alternative techniques for people with treatment under general anesthesia. J Clin Experimental
special needs. Spec Care Dentist 2009;29(1):2-8, quiz Dent 2015;7(1):e106.
67-8. 17. Malden PE, Thomson WM, Jokovic A, Locker D. Chan-
4. White HR, Lee JY, Rozier RG. The effects of general ges in parent-assessed oral health related quality of life
anesthesia legislation on operating room visits by pre- among young children following dental treatment under
school children undergoing dental treatment. Pediatr general anaesthestic. Community Dent Oral Epidemiol
Dent 2008;30(1):500-5. 2008;36(2):108-17.
5. American Academy of Pediatric Dentistry Oral Health 18. Cantekin K, Yildirim MD, Cantekin I. Assessing change
Policy and Research Center. Technical Report 2-2012: in quality of life and dental anxiety in young children
An Essential Health Benefit: General Anesthesia for following dental rehabilitation under general anesthesia.
Treatment of Early Childhood Caries. Available at: “http: Pediatr Dent 2014;36(1):12E-17E.
//www.aapd.org/assets/1/7/POHRPCTechBrief2.pdf ”. 19. Klaassen MA, Veerkamp JS, Hoogstraten J. Young chil-
Accessed September 7, 2015. (Archived by WebCite at:
“http://www.webcitation.org/6fXaZXBRg”)
® dren’s oral health-related quality of life and dental fear
after treatment under general anaesthesia: A randomized
6. Escanilla-Casal A, Aznar-Gómez M, Viaño JM, López- controlled trial. Eur J Oral Sci 2009;117(3):273-8.
Giménez A, Rivera-Baró A. Dental treatment under
general anesthesia in a group of patients with cerebral References continued on the next page.

20. Antunes LAA, Andrade MRTC, Leão ATT, Maia LC, 23. White HR, Lee JY, Rozier RG. The effects of general
Luiz R. Change in the quality of life of children and anesthesia legislation on operating room visits by pre-
adolescents younger than 14 years old after oral health school children undergoing dental treatment. Pediatr
interventions: A systematic review. Pediatric Dent 2013; Dent 2008;30(1):500-5.
35(1):37-42. 24. American Academy of Pediatric Dentistry. Policy on
21. Cunnion DT, Spiro A, Jones JA, et al. Pediatric oral model dental benefits for infants, children, adolescents,
health-related quality of life improvement after treatment and individuals with special health care needs. Pediatr
of early childhood caries: A prospective multisite study. Dent 2016;38(special issue):100-2.
J Dent Child 2010;77(1):4-11.
22. American Dental Association. Benefits for services by
qualified practitioners (1989:546). In: ADA Current
Policies Adopted 1954-2013. Chicago, Ill.: American
Dental Association; 2014:94.

ORAL HEALTH POLICIES: REIMBURSEMENT OF FEES RELATED TO ANOMALIES
Policy on Third-Party Reimbursement for Oral

Health Care Services Related to Congenital and
Acquired Orofacial Anomalies
2016 third-party reimbursement for oral health care services related to
congenital and acquired orofacial anomalies. The Reference Manual
Purpose techniques and readily adapt to appliances that replace miss-

The American Academy of Pediatric Dentistry (AAPD) values ing teeth and improve function, appearance, and self-image.
the unique qualities of each person and the need to ensure During the period of facial and oral growth, appliances require
maximal health attainment for all, regardless of developmental frequent adjustment and have to be remade as the individual
anomalies or other special health care needs. Recognizing that grows.
patients with craniofacial anomalies require oral health care as These patients often are denied coverage for initial appli-
a direct result of their craniofacial condition and that these ance construction and, more frequently, replacement of
services are an integral part of the rehabilitative process,1 AAPD appliances as the child grows. Third-party payors legally may
advocates providing benefits for provision of comprehensive control the coverage of these services by limiting contractual
oral health care services throughout life. benefits. The distinction between congenital and acquired
anomalies involving the orofacial complex and those involving
Methods other parts of the body often seems arbitrary and unfair. For
This policy was developed by the Clinical Affairs Committee instance, health care policies may provide reimbursement for
adopted in 1996, and last revised by the Council of the necessary prosthesis required for congenitally missing ex-
Clinical Affairs. This document is an update of the previous tremities and its replacement as the individual grows, but deny
version, revised in 2011. It is based on review of current dental benefits for the initial prosthesis and the necessary periodic
and medical literature, including a search of the PubMed /
MEDLINE database using the terms: orofacial anomalies and
® replacement for congenitally missing teeth. Third-party payors
frequently will refuse to pay for oral health services even when
cleft OR anondontia OR oligodontia OR ectodermal dysplasia they clearly are associated with the complete rehabilitation
AND insurance OR third-party OR reimbursement; fields: all; of the craniofacial condition.7
limits: within the last 10 years, human, English. Seventy-two The Patient Protection and Affordable Care Act of 20108
articles matched these criteria. Papers for review were chosen “is silent on the features of what might constitute a fair and
from this list and from the references within selected articles. acceptable medical necessity standard in qualified health
When data did not appear sufficient or were inconclusive, plans”9. Despite being included as one of the essential health
policies were based upon expert and/or consensus opinion by benefits in all qualified plans, federal regulations allow sig-
experienced researchers and clinicians. nificant flexibility to plans that include dental care, and these
services often are restricted. The restriction of these benefits
Background largely affects children with multiple chronic conditions who
Congenital and acquired orofacial anomalies (e.g., ectodermal have complex developmental needs and use specialty care. 9
dysplasia, cleft defects, oral cancer) can have significant Furthermore, clerical personnel and professional consultants
negative functional, esthetic, and psychological effects on employed by third-party payors often make benefit determina-
individuals and impose a financial burden to their families.1-4 tions based on arbitrary distinction between medical versus
The oral health care needs of these patients are unique, impact dental anomalies, ignoring important functional and medical
their overall health, and necessitate special considerations.5 relationships. Evaluation and care provided for an infant,
Patients with craniofacial anomalies often require specialized
oral health care as a direct result of their condition to promote
normal function and development. These services are medic- ABBREVIATION
ally necessary and an integral part of the rehabilitative process.6 AAPD: American Academy Pediatric Dentistry.
Young children benefit from esthetic and functional restorative

ORAL HEALTH POLICIES: REIMBURSEMENT OF FEES RELATED TO ANOMALIES
child, or adolescent by a cleft lip/palate, orofacial, or cranio- 2. Murdock S, Lee JY, Guckes A, Wright JT. A cost analysis
facial deformities team have been described as the optimal of dental treatment for ectodermal dysplasia. J Am Dent
way to coordinate and deliver complex services.7 This approach Assoc 2005;136(9):1273-5.
may provide additional documentation to facilitate medical 3. National Foundation for Ectodermal Dysplasias. Param-
necessity of dental rehabilitation. eters of Oral Health Care for Individuals Affected by
Ectodermal Dysplasias. 2nd revision 2015. National
Policy statement Foundation for Ectodermal Dysplasias. Mascoutah, Ill.
The AAPD encourages all policy makers and third-party Available at: “https://juyhw1n8m4a3a6yng24eww91-
payors to consult the AAPD in the development of benefit wpengine.netdna-ssl.com/wp-content/uploads/2016/07/
plans that best serve the oral health interests of infants, chil- NFEDParametersOfOralHealthCare.pdf ”. Accessed
dren, adolescents, and individuals with special health care
needs.
®
June 15, 2016. (Archived by WebCite at: “http://www.
webcitation.org/6tkM4D1rS”)
The AAPD strongly believes that the dentist providing 4. Coffield KD, Phillips C, Brady M, Roberts MW, Strauss
the oral health care for the patient determines the medical RP, Wright JT. The psychosocial impact of developmental
indication and justification for treatment for patients with dental defects in people with hereditary amelogenesis
congenital and acquired orofacial anomalies. imperfecta. J Am Dent Assoc 2005;136(5):620-30.
The AAPD encourages third-party payors to: 5. American Academy of Pediatric Dentistry. Guideline on
• recognize that congenital and acquired orofacial anom- management of dental patients with special health care
alies require care over the life-time of the patient. needs. Pediatr Dent 2016;38(special issue):171-6.
• include oral health services related to these facial and 6. American Academy of Pediatric Dentistry. Policy on
dental anomalies as benefits of health insurance without medically-necessary care. Pediatr Dent 2016;38(special
discrimination between the medical and dental nature issue):18-22.
of the defect. These services, optimally provided by the 7. Strauss RP. The organization and delivery of craniofacial
craniofacial team, include, but are not limited to, initial services: The state of the art. Cleft Palate Craniofac J 1999;
appliance construction, periodic examinations, and re- 36(3):189-95.
placement of appliances. 8. 111th U.S. Congress. Patient Protection and Affordable
• provide payable benefits for oral health services related Care Act. Public Law 111-148—March. 23, 2010. U.S.
to these facial and dental anomalies. Government Publishing Office. Available at: “https://
www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/
References PLAW-111publ148.pdf ”. Accessed September 16, 2016.
1. American Cleft Palate-Craniofacial Association. Parame-
ters for Evaluation and Treatment of Patients with Cleft org/6tkMHiKIS”)
®
Lip/Palate or Other Craniofacial Anomalies. Revised ed. 9. American Academy of Pediatrics. Defining and deter-
Chapel Hill, N.C.: American Cleft Palate-Craniofacial mining medical necessity in Medicaid managed care.
Association; November 2009. Available at: “http://acpa Pediatrics 2014;134(3):516-22.
-cpf.org/wp-content/uploads/2017/06/Parameters_
Rev_2009_9_.pdf ”. Accessed June 15, 2016. (Archived by
®
WebCite at: “http://www.webcitation.org/6tkLW3x21”)

ORAL HEALTH POLICIES: REIMBURSEMENT OF FEES TO SEALANTS
Policy on Third-Party Reimbursement of Fees

Related to Dental Sealants
2016 third-party reimbursement of fees related to dental sealants. The
Purpose reduce the number of lesions with any viable bacteria by 50

The American Academy of Pediatric Dentistry (AAPD) percent.8
recognizes that the placement of sealants and their continued Current data show that, although initial sealant retention
maintenance are scientifically-sound and cost-effective tech- rates are high, sealant loss does occur.5,9 It is in the patient’s
niques for prevention of pit and fissure caries and to prevent interest to receive periodic evaluation of sealants for mainte-
the progression of early noncavitated carious lesions. nance or replacement.9,10 Without recall and maintenance,
sealant failure will compound over time, leaving previously
Methods sealed surfaces with a caries susceptibility equal to that of
This policy was developed by the Clinical Affairs Committee surfaces that never were sealed.11 With appropriate follow-up
adopted in 1999, and last revised by the Council of Clinical care, the success rate of sealants may be 80 to 90 percent, even
of Affairs. This document is an update of the previous version, after a decade.2,10
revised in 2011, and is based upon a review of current dental Although sealants are safe and effective, their use continues
and medical literature related to dental sealants. The update to be low.12 Sealants are particularly effective in preventing
used electronic database and hand searches of articles using pit and fissure caries. They provide cost savings if placed on
the terms: dental sealants AND insurance; fields: all; limits: patients during periods of greatest risk by delaying or avoid-
within the last 10 years, humans, English. Sixty-one articles ing invasive treatment and the destructive cycle of dental
matched these criteria. Papers for review were chosen from this caries.5,13-15 However, initial insurance coverage for sealants
list and from the references within selected articles. When data often is denied based on the age of the patient, and insurance
did not appear sufficient or were inconclusive, recommenda- coverage for repair and/or replacement may be limited.16-18
tions were based upon expert and/or consensus opinion by
experienced researchers and clinicians. Policy statement
The AAPD encourages all policy makers and third-party
Background payors to consult the AAPD in the development of benefit
According to national estimates, by 17 years of age, 68 per- plans that best serve the oral health interests of infants, chil-
cent of children in the United States have experienced caries.1 dren, adolescents, and individuals with special health care needs.
Data indicate that around 40 percent of children ages 2-8 The AAPD advocates that the dentition periodically be
years have experienced dental caries in their primary teeth, evaluated for developmental defects and deep pits and fissures
with 44 percent of carious lesions in the pits and fissures.2,3 that may contribute to caries risk and that sealants be placed
As much as 90 percent of all caries in school-aged children on primary and permanent teeth judged to be at risk for
occurs in pits and fissures.4 The teeth at highest risk by far are dental caries. AAPD encourages placement of dental sealants
permanent first and second molars where fluoride has its least on early (noncavitated/incipient) carious lesions to inhibit lesion
preventive effect on the pits and fissures. Any tooth, including progression. Once sealants have been placed, they should be
primary teeth and permanent teeth other than molars, may evaluated for repair or replacement as part of a periodic den-
benefit from sealant application due to fissure anatomy and tal examination.
caries risk factors.4-6 Caries risk may increase due to changes The AAPD encourages third-party payors to:
in patient habits, oral microflora, or physical condition, and • recognize that dental sealants are scientifically-sound and
unsealed teeth subsequently might benefit from sealant appli- cost-effective techniques for primary or permanent teeth
cation.4,5 Placement of pit and fissure sealants significantly at increased risk for caries and for early (noncavitated/
reduces the percentage of incipient noncavitated carious le- incipient) carious lesions.
sions that progress in children, adolescents, and young adults,
compared to unsealed teeth, for as long as five years after
ABBREVIATION
sealant placement.7 When placed over existing caries, sealants AAPD: American Academy Pediatric Dentistry.
lower the number of viable bacteria by at least 100-fold and

ORAL HEALTH POLICIES: REIMBURSEMENT OF FEES TO SEALANTS
• base third-party coverage for sealants on a patient’s caries 8. Oong EM, Griffin SO, Kohn WG, Gooch BF, Caufield
risk rather than age. Timing of the eruption of teeth can PW. The effect of dental sealants on bacteria levels in
vary widely. Furthermore, caries risk may increase at caries lesions: A review of the evidence. J Am Dent Assoc
any time during a patient’s life. 2008;139(3):271-8.
9. Gooch B, Griffin S, Kolavic Gray S, et al. Preventing
The AAPD shall continue to work with other dental or- dental caries through school-based sealant programs. J
ganizations, the insurance industry, and consumer groups to Am Dent Assoc 2009;140(11):1356-65.
make the advantages of dental sealants understood and to 10. American Academy of Pediatric Dentistry. Guideline on
seek reimbursement for fees associated with their placement, periodicity of examination, preventive dental services,
maintenance, and repair. anticipatory guidance/counseling and oral treatment for
infants, children and adolescents. Pediatr Dent 2016;38
References (special issue):133-41.
1. Beltrán-Aguilar ED, Barker LK, Canto MT, et al. Surveil- 11. Griffin SO, Gray SK, Malvitz DM, Gooch BF. Caries
lance for dental caries, dental sealants, tooth retention, risk in formerly sealed teeth. J Am Dent Assoc 2009;
edentulism, and enamel fluorosis – United States 1988- 140(4):415-23.
1994 and 1999-2002. MMWR Surveill Summ 2005; 12. U.S. Deparment of Health and Human Services. Healthy
54:1-43. people 2010. Rockville, Md.: U.S. Deparment of Health
2. Tinanoff N, Coll JA, Dhar V, Maas WR, Chhibber S, and Human Services, National Institutes of Health;
Zokaei L. Evidence-based update of pediatric dental 2000.
restorative procedures: Preventative strategies. J Clin 13. Weintraub JA. Pit and fissure sealants in high-caries
Pediatr Dent 2015;39(3):193-7. risk individuals. J Dent Educ 2001;65(10):1084-90.
3. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental 14. Quiñonez RB, Downs SM, Shugars D, Christensen J,
caries and sealant prevalence in children and adolescents Vann WF. Assessing cost effectiveness of sealant place-
in the United States, 2011-2012. Centers for Disease ment in children. J Pub Health Dent 2005;65(2):82-9.
Control and Prevention; NCHS Data Brief, no. 191. 15. American Dental Association. Statement on preventive
Hyattsville, Md.: National Center for Health Statistics; coverage in dental benefits plans. In: ADA Current
2015. Policies – Adopted 1954-2013. Chicago, Ill.: American
4. Beauchamp J, Caufield PW, Crall JJ, et al. Evidence-based Dental Association; 2013:89.
clinical recommendations for the use of pit-and-fissure 16. Neusser S, Krauth C, Hussein R, Bitzer EM. Clinical
sealants. J Am Dent Assoc 2008;139(3):257-68. effectiveness and cost-effectiveness of fissure sealants in
5. American Academy of Pediatric Dentistry. Guideline children and adolescents with a high caries risk. GMS
on restorative dentistry. Pediatr Dent 2016;38(special Health Technol Assess 2014;10:Doc02.
issue):250-62. 17. Chi D, van der Goes D, Ney JP. Cost-effectiveness of
6. Unal M, Oznurhan F, Kapdan A, Durer A. A comparative pit-and-fissure sealants on primary molars in Medicaid-
clinical study of three fissure sealants on primary teeth: enrolled children. Am J Public Health 2014;104(3):
24-month results. J Clin Pediatr Dent 2015;39(2):113-9. 555-61.
7. Griffin SO, Oong E, Kohn W, et al. The effectiveness of 18. Ney JP, van der Goes DN, Chi DL. Economic modeling
sealants in managing caries lesions. J Dent Res 2008;87 of sealing primary molars using a “value of information”
(2):169-74. approach. J Dent Res 2014;93(9):876-81.

ORAL HEALTH POLICIES: FEES CAPPING OF NON-COVERED SERVICES
Policy on Third-Party Fees Capping of Non-Covered

Services
2017 third-party fees capping of non-covered services. The Reference
Purpose • it is unreasonable to allow plans to set fees for services

The American Academy of Pediatric Dentistry (AAPD) in which they have no financial liability, and that may
supports dental benefit plan provisions designed to meet the not cover the overhead expense of the services being
oral health needs of patients by facilitating, beginning at birth, provided. When this provision precludes dentist partici-
the delivery of diagnostic, preventive, and therapeutic services pation in a reimbursement plan, subscribers realize less
in a comprehensive, continuously accessible, coordinated and choice in their selection of available providers. In many
family-centered manner.1 A well-constructed dental benefit cases, especially in rural or other areas with limited gen-
plan respects and meets the needs of the plan purchaser, eral or specialty practitioners, this adversely affects the
subscriber/patient, and provider. care. This is particularly true for vulnerable populations,
including individuals with special health care needs.
Methods • for dentists forced to accept this provision, the artificial
This policy was developed by the Council on Dental Benefits pricing of uncovered services results in cost-shifting
Programs and adopted in 2012. This revision by the Council from those covered under a particular plan to uncovered
of Clinical Affairs included a review and analysis of state patients. Thus, the uninsured and those covered under
laws and pending legislation prohibiting the capping of nontraditional indemnity or other plans will shoulder the
covered services by third-party providers, related federal costs of these provisions. Capping of non-covered serv-
legislation, and the American Dental Association’s Policy on ices is not cost saving; it is cost-shifting – often to the
Maximum Fees for Non-Covered Services2. most vulnerable populations and to those least able to
afford healthcare.
Background • the ability to cap non-covered services allows insurance
The American Dental Association (ADA) defines covered plans to interfere with the patient-doctor relationship.
service as “any service for which reimbursement is actually
provided on a given claim” and noncovered service as “any The House of Delegates of the ADA in 2009 adopted
service for which the third-party provides no reimbursement”. Resolution 59H which opposed third party contract provi-
Capping of non-covered services occurs when an insurance sions that establish fee limits for non-covered services and
carrier sets a maximum allowable fee for a service ineligible called for state and federal legislation to prohibit such prac-
for third-party reimbursement. While most contractual matters tices.4 Legislation to prohibit a dental insurer or dental service
between insurers and providers are those of a private business plan from limiting fees for services not covered under the
relationship, this particular business practice is contrary to the plan, is the law in 35 states4 and has been introduced in most
public interest for the following reasons: other states. Such legislation allows the dentist to utilize the
• larger dental benefit carriers with greater market share usual and customary fee for services not covered by the plan.
and more negotiating power are favored in this arrange-
ment. While dentists may refuse to contract with Policy statement
smaller plans making this requirement, they are unable The AAPD believes that dental benefit plan provisions which
to make the same decision with larger plans controlling establish fee limitations for non-covered services are not in
greater numbers of enrollees. Eliminating this practice the public’s interest and should not be imposed through
levels the playing field for all insurers and encourages provider contracts.
greater competition among dental plans. If smaller plans
and insurers are unable to survive, the group purchaser
and subscriber are ultimately left with less market choice ABBREVIATIONS
and potentially higher insurance cost. ADA: American Dental Association. AAPD: American Academy
Pediatric Dentistry.

ORAL HEALTH POLICIES: FEES CAPPING OF NON-COVERED SERVICES
References 4. American Academy of Pediatric Dentistry. Non-covered

1. American Academy of Pediatric Dentistry. Policy on the benefits legislation. Available at: “http://www.pediatric
dental home. Pediatr Dent 2017;39(6):29-30. dentistrytoday.org/2016/March/Ll/2/news/article/535/”.
2. American Dental Association. Maximum fees for non- Accessed January 22, 2017. (Archived by Website at: ®
covered services. In: American Dental Association “http://www.webcitation.org/6niRwFAVk”)
Current Policies Adopted 1954-2015. Chicago, Ill.:
American Dental Association; 2015:112.
3. American Dental Association. Health care reform
legislation: Side-by-side Comparison. Available at: “http:
//www.aapd.org/assets/news/upload/2010/3827.pdf ”.
Accessed January 22, 2017. (Archived by WebCite at:
“http://www.webcitation.org/6niQHlMUM”)
®

ORAL HEALTH POLICIES: AUDITS, ABUSE AND FRAUD
Policy on Third-Party Payor Audits, Abuse, and

Fraud
2019 third-party payor audits, abuse, and fraud. The Reference Manual
Dentistry; 2020:147-50.
Purpose Audit: “planned and documented activity performed by

One of the aims of the Deficit Reduction Act1, approved by qualified personnel to determine by investigation, examination,
the U.S. Congress in 2005, was to prevent Medicaid fraud and or evaluation of objective evidence, the adequacy and com-
abuse through an audit process. Despite the good intentions pliance with established procedures, or applicable documents,
of this law, experts predicted health care providers would see and the effectiveness of implementation”.5 After receiving a
more investigations, enforcement actions, and whistleblower notice of an impending audit from a third-party payor, the
cases and would need to devote more resources toward com- dentist should ascertain in writing the type and scope of audit
pliance.2 Pediatric dentists play a critical role in the Medicaid to be conducted.6,7
program, and there will be negative impact on access to care
if providers are burdened with excessive regulations and un- Fraud: “an intentional deception or misrepresentation made by
founded audits. Nonetheless, the American Academy of Pedi- a person with the knowledge that the deception could result
atric Dentistry (AAPD) supports efforts to eliminate Medicaid in some unauthorized benefit to him or some other person.”3
abuse. Such unprofessional conduct could result in loss of
membership status in AAPD.2 This policy is intended to help Recovery audit contractor (RAC): one who reviews claims on
AAPD members understand the audit process, both internal a post-payment basis. The RAC detects and corrects past
and external audits. improper payments so that Centers for Medicare and Medi-
caid Services (CMS) and carriers, fiscal intermediaries, and
Methods Medicare administrative contractors can implement actions
This document was developed by the Council on Clinical that will prevent future improper payments.8
Affairs and adopted in 2014. This policy is based upon a
review of current dental and medical literature, including a Third-party payor: “an organization other than the patient
®
literature search of the PubMed /MEDLINE electronic data-
base using the terms: dental audits, dental abuse and fraud,
(first party) or health-care provider (second party) involved
in the financing of health care services.”9
peer review, dental peer review committee, provider profiling,
practice management, Early and Periodic Screening, Diagnosis, Background
and Treatment (EPSDT) field: all; limits: within the last 10 External audits are increasingly common for a full range of
years; human; English. Papers for review were chosen from health care providers. Dentists are no exception, as some pedi-
this list as well as references within the selected articles. atric dentists have experienced. If a provider requests payment
from third-party payors, the claims may be subject to review
Definitions by a RAC, a private entity that reviews paid claims and, in
Abuse: “provider practices that are inconsistent with sound some cases, earns contingency fees for improper payments it
fiscal, business, or medical practices, and result in an unnec- retrieves. Private and public third-party payors use audits as
essary cost to the Medicaid program, or reimbursement for a mechanism to recoup over-payments, inspect for potential
services that are not medically necessary or that fail to meet improper behavior, and possibly guide health care providers
the professionally recognized standards for health care. It also to control utilization and costs.10 Notably, there can be serious
includes beneficiary practices that result in unnecessary cost financial and even criminal penalties associated with billing
to the Medicaid program.”3 The AAPD supports medically- errors.11
necessary care (MNC) and recognizes that dental care is
medically necessary for the purpose of preventing and
ABBREVIATIONS
eliminating orofacial disease, infection, and pain, restoring the
AAPD: American Academy Pediatric Dentistry. CMS: Centers for
form and function of the dentition, and correcting facial Medicare and Medicaid Services. EPSDT: Early and Periodic Screen-
disfiguration or dysfunction.4 ing, Diagnosis, and Treatment. MNC: Medically-necessary care. RAC:
Recovery audit contractor.

In 2017, an estimated $37 billion, or 10 percent, of the Peer review as part of audit outcomes
federal Medicaid funds were absorbed by improper pay- The AAPD supports peer review as a way to offer information
ments, which include fraud and abuse as well as unintentional and support to dentists who need to review best practices
mistakes such as paper errors.12 Improper payments can occur regarding chart documentation, coding, and billing practices
when funds go to the wrong recipient, the recipient receives related to third-party payors. This should be offered in lieu
the incorrect amount of funds (either an underpayment or of financial penalties when an audit shows that no intent to
overpayment), documentation is not available to support a fraud was present, but that the dentists need education to
payment, or the recipient uses the funds in an improper improve their practice systems. It provides practicing dentists
manner.12 a means to preserve their reputation and good standing in the
The AAPD recognizes the concern its members have regard- community and fosters risk management, accountability, and
ing these external audits. The AAPD encourages its members self-regulation among dental professionals. 16 This model
to develop internal self-audit programs to address these would be consistent with the peer review practices that occur
challenges. Internal audits are used in order to pre-emptively when clinical decision making is in question. The intent of
detect discrepancies before the external authorities can discover peer review is to resolve discrepancies between the dentists and
them and impose penalties.10 Given the heightened concern third-party payors expeditiously, fairly, and in a confidential
for compliance to avoid an external audit, internal audits have manner.16
taken on importance. A compliance program generally will
incorporate a credible internal audit system, which means that Best practices for chart documenting, coding, and billing
it must be prepared to respond to an external audit by various The AAPD supports the education of pediatric dentistry
authorities. In addition, some pediatric dentists have discovered residents, pediatric dentists, and their staff to ensure good
that an internal audit system can be developed so that it not understanding of appropriate coding and billing practices.
only addresses the external audit, but also serves other quality The AAPD, therefore, supports the creation of educational
of care and performance improvement purposes.10 resources and programs that promote best practices, which may
include:
Credentials of auditors • programming offered at the AAPD’s Annual Session or
The Affordable Care Act required that each state Medicaid other AAPD-sponsored continuing education course.
program use at least one RAC beginning in 2011. 13 Some • programs offered by pediatric dentistry state unit and
states have started employing the RACs to aid in recovery of district organizations.
improper payments.14 The AAPD strongly believes that, while • the creation of a web-based tutorial for dentists and
audits are a part of third-party payment contracts and are their staff, including the states’ dental Medicaid provider
necessary to protect the integrity of these programs, such manuals and frequently asked questions regarding
audits must be completed by those who have credentials on Medicaid.
par with the dental provider being audited. For example, pedi- • partnering with other public/private organizations and
atric dentists must be audited by a dentist who specializes in agencies to distribute ‘Medicaid Updates’ that can be
pediatric dentistry and who understands the clinical guidelines received via e-mail and augmenting Medicaid Compliance
and standards of care which have been adopted and followed for the Dental Professional webinars offered jointly by
by their specialty. The AAPD is adamantly opposed to audi- AAPD and CMS.17
tors receiving financial incentives for any money recuperated • the development of a third-party payor submission
through these audits. This represents a conflict of interest. compliance program.
Provider profiling Medicaid policies that conflict with AAPD clinical practice
The AAPD is opposed to provider profiling, a strategy that may guidelines
be used by health plans to assess efficiency among providers, The AAPD is opposed to Medicaid programs that have
and believes that dentist providers selected for audits should policies which are in direct conflict with AAPD clinical
be chosen randomly or with compelling evidence that makes practice recommendations and are of detriment to patient
them an outlier compared to peers practicing in similar geo- care. For example, in several states, children are not receiving
graphic areas, on similar populations of patients, and within appropriate dental treatment covered by EPSDT because
the same specialty. Claims-based data used for provider pro- there is a refusal to reimburse providers for EPSDT-covered
filing are not collected exclusively for performance assessment dental services.18 According to CMS, “federal law also requires
and, as a result, may be irrelevant or inadequate for profiling.15 that states inform all families about EPSDT coverage”19;
Furthermore, the procedure codes included in claims-based the AAPD supports this requirement to enable caregivers to
data cannot fully characterize the nature of a particular episode seek necessary dental treatment for their children.
of care and may fail to account for variations in a patient’s
baseline status, socioeconomic considerations, compliance with
treatment, and access to care.15

Policy statement • supports the creation of educational resources and

Dental care is medically necessary to prevent and eliminate programs that promote appropriate coding and billing
orofacial disease, infection, and pain, to restore the form and practices.
function of the dentition, and to correct facial disfiguration • opposes Medicaid programs that have policies in direct
or dysfunction. MNC is based upon current preventive and conflict with AAPD clinical practice recommendations
therapeutic practice guidelines formulated by professional and are of detriment to patient care.
organizations with recognized clinical expertise. Expected • endorses the enforcement of the “federal law that re-
benefits of MNC outweigh potential risks of treatment or no quires that states inform all families about EPSDT
treatment. Early detection and management of oral conditions coverage”18 to enable caregivers to seek necessary dental
can improve a child’s oral health, general health and well- treatment for their children.
being, school readiness, and self-esteem. Early recognition,
prevention, and intervention could result in savings of health References
care dollars for individuals, community health care programs, 1. U.S. Congress. Deficit Reduction Act of 2005. Pub. No.
and third-party payors. Because a child’s risk for developing 109-171, 120 Stat. 119, Feb 8, 2006. U.S. Government
dental disease can change over time, continual professional Printing Office. Available at: “http://www.gpo.gov/fdsys/
reevaluation and preventive maintenance are essential for good pkg/BILLS-109s1932enr/pdf/BILLS-109s1932enr.pdf ”.
oral health. Value of services is an important consideration,
and all stakeholders should recognize that cost-effective care
“http://www.webcitation.org/778mgvFQF”)
®
is not necessarily the least expensive treatment.4 2. American Academy of Pediatric Dentistry. Constitution
The AAPD: and Bylaws of the American Academy of Pediatric Den-
• encourages it members and all third-party payors to tistry. Available at: “https://www.aapd.org/assets/1/7/2018
support efforts to eliminate Medicaid abuse. -19_Constitution_and_Bylaws.pdf ”. Accessed March 25,
• opposes any of its dentist members committing abuse
and fraud as it relates to their relationship with third- citation.org/778n92Cae”)
®
party payors. 3. U.S Government. Code of Federal Regulations, Title 42:

• recognizes the concern its members have regarding Public Health Part 455, Program Integrity: Medicaid.
these external audits. Centers for Medicare & Medicaid Services. 2018. Avail-
• encourages its members to develop internal self-audit able at: “https://www.govinfo.gov/app/details/CFR-2018
programs to address these challenges. -title42-vol4/CFR-2018-title42-vol4-sec455-2”. Accessed
• cautions against ill-informed or misguided investiga- July 13, 2019.
tions that may discourage dental provider participation 4. American Academy of Pediatric Dentistry. Definition of
in Medicaid.20 medically-necessary care. Pediatr Dent 2018;40(6):15.
• strongly believes that, while audits are a part of third- 5. Project Auditors, LLC. Auditor Dictionary: Audit. Avail-
party payment contracts and are necessary to protect able at: “https://www.projectauditors.com/Auditor_Dic
the integrity of these programs, such audits must be tionary/AuditorDictionary.php”. Accessed July 12, 2019.
completed by those who have credentials on par with 6. Oberman SJ. Dental practice audits. Dental Tribune
the dental provider being audited. International. November 12, 2010. Available at: “https:
• adamantly opposes auditors receiving financial incentives //www.dental-tribune.com”. Accessed July 12, 2019.
for any money recuperated through audits. 7. Manchie M. Dentists facing compliance audits have ADA
• opposes provider profiling and believes that dentist resources in their reach. ADA News. April 16, 2018.
providers selected for audits should be chosen randomly Available at: “https://www.ada.org/en/publications/ada
or with compelling evidence that makes them an outlier -news/2018-archive/april/dentists-facing-compliance-audits-
as compared to their peers who practice in similar have-ada-resources-in-their-reach”. Accessed July 13, 2019.
geographic areas, on similar populations of patients, 8. Centers for Medicare and Medicaid Services. Medicare
and within the same specialty. fee for service recovery audit program. Available at:
• supports peer review in lieu of financial penalties when “https://www.cms.gov/Research-Statistics-Data-and-
an audit shows that no intent to fraud was present, to Systems/Monitoring-Programs/Medicare-FFS-Compliance-
offer information and support to dentists who need to Programs/Recovery-Audit-Program/”. Accessed March
re-acquaint themselves on best practices regarding chart
documentation, coding, and billing practices relating citation.org/778oXZa2y”)
®
to third-party payors. 9. American Dental Association. Glossary of Dental Clinical

• supports the education of pediatric dentistry residents, and Administrative Terms. American Dental Association,
pediatric dentists, and their staff to ensure a good under- Chicago, Ill. Available at: “https://www.ada.org/en/
standing of appropriate coding and billing practices. publications/cdt/glossar y-of-dental-clinical-and-
administrative-ter#t”. Accessed July 13, 2019.

10. Jose DE. Payor audits: Preparation, response, and oppor- 17. Mouden LD, U.S. Department for Health and Human
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2010. U.S. Government Printing Office. Available at: 19. U.S. Department for Health and Human Services, Centers
“http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/ for Medicare and Medicaid Services. Guide to children’s
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for Medicare and Medicaid Services. Medicaid Integrity and Medicaid Services, Washington, D.C. Available at:
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Medicare-Medicaid-Coordination/Fraud-Prevention/ 20. Litch CS. The government’s Medicaid fraud tools: Good
FraudAbuseforProfs/Downloads/NJfy12.pdf ”. Accessed reason to stay out of trouble and strategies to preempt
July 12, 2019. trouble. American Academy of Pediatric Dentistry. Chi-
15. Charvet H. The problem with physician profiling: What cago, Ill.; 2007. Available at: “http://www.aapd.org/
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16. American Dental Association. How the dental peer review
system works and what you expect from it. American
Dental Association, Chicago, Ill. Available at: “https://
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peer_review_overview.pdf?la=en”. Accessed July 12, 2019.

ORAL HEALTH POLICIES: ROLE OF PEDIATRIC DENTISTS AS PROVIDERS
Policy on the Role of Pediatric Dentists as Both

Primary and Specialty Care Providers
2018 the role of pediatric dentists as both primary and specialty care
providers. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2020:151.
Purpose The AAPD respects the rights of employers to negotiate

The American Academy of Pediatric Dentistry (AAPD) health care benefits for their employees. Sometimes, third-
emphasizes that health care providers and other interested third party payors do not recognize pediatric dentists as primary
parties must recognize the dual role that pediatric dentists care providers. This position restricts access to pediatric
play in the provision of professional preventive and thera- dentists for children who have reached a predetermined age
peutic oral health care, which includes both primary and and/or who may be best served by specialized oral health care
specialty care services. providers and counseling. In some instances, this restriction
necessitates a specialty referral to a pediatric dentist prior to
Methods evaluation.
This policy was developed by the Council on Clinical Affairs
and adopted in 2003. This is a revision of the last version, Policy statement
revised in 2008 and reaffirmed in 2013. It was based on a The AAPD recognizes that infants, children, adolescents, and
review of Accreditation Standards for Advanced Specialty individuals with special health care needs have the right to
Training Programs in Pediatric Dentistr y 1 and the AAPD quality oral health care. The AAPD encourages third-party
position paper on the role of pediatric dentists as primary and payors to recognize pediatric dentists as both primary and
specialty care providers.2 An electronic search was conducted specialty oral health care providers and to refrain from age-
using the terms pediatric dentist, pediatric specialist, primary related restrictions when a parent or referring clinician desires
care provider, dual care provider, and specialty care provider. to utilize the services and expertise of a pediatric dentist to
establish a dental home or for limited specialized care.
Background
“Pediatric dentistry is an age-related specialty that provides References
both primary and comprehensive preventive and therapeutic 1. American Dental Association Commission on Dental
oral health needs for infants and children through adoles- Accreditation. Accreditation standards for advanced spe-
cence, including those with special health care needs.”1 The cialty education programs in pediatric dentistry. Chicago,
American Dental Association, the American Academy of Ill.; 2017. Available at: “https://www.ada.org/~/media/
General Dentistry, and the AAPD all recognize the pediatric CODA/Files/ped.pdf?la=en”. Accessed March 16, 2018.
dentist as both a primary care provider and specialty care ®
provider. The dual role of pediatric dentists is similar to that org/6xxyl5TyJ”)
of pediatricians, gynecologists, and internists in medicine. 2. American Academy of Pediatric Dentistry, Council on
Within the medical profession, clinicians and third-party Dental Benefits Programs. Position paper: The role of
payors recognize these physicians in a dual role and have pediatric dentists as primary and specialty care providers.
designed payment plans to accommodate this situation. Chicago, Ill.: American Academy of Pediatric Dentistry;
2002.
ABBREVIATION
AAPD: American Academy Pediatric Dentistry.

ORAL HEALTH POLICIES: TRANSITIONING DENTAL HOMES FOR INDIVIDUALS WITH SHCN
Policy on Transitioning from a Pediatric-Centered

to an Adult-Centered Dental Home for Individuals
with Special Health Care Needs
2016 transitioning from a pediatric-centered to an adult-centered dental
home for individuals with special health care needs. The Reference
Purpose Transitions are part of normal, healthy development and

The American Academy of Pediatric Dentistry (AAPD) occur across the life span. Health care transition for older
recognizes the importance of transitioning patients with special adolescents with SHCN is a dynamic process that seeks to
health care needs (SHCN) to an adult dental home as they meet their individual needs. The goal is to maximize lifelong
reach the age of majority. Finding a dental home1 to address functioning and potential through uninterrupted provision
their special circumstances while providing all aspects of oral of high-quality, developmentally-appropriate health care as
care in a comprehensive, continuously accessible, coordinated, the individual moves from adolescence into adulthood. The
and family-centered manner may be a challenge. This policy cornerstones of patient-centered health care are flexibility, re-
addresses transition of young adult patients with SHCN and sponsiveness, continuity, comprehensiveness, and coordination.6
identifies barriers that may challenge delivery of oral health
care to this population. Transitioning patients with SHCN
Facilitating health care transition for SHCN patients has
Methods received national attention from other organizations recogni-
This policy was developed by the Council on Clinical Affairs zing the need to support the process.4,7,8 The medical com-
and adopted in 2011. This document is an update of the munity, specifically, and the broader health care community
original version. The revision used electronic database and (including dentistry) have yet to ensure that young people
hand searches of dental and medical literature, using the with SHCN who are the most dependent on coordinated
terms: special needs, disabled patients, handicapped patients, health care services are able to make the transition to the
adolescent development, adolescent health, special health care adult health care system and still receive the services that they
needs AND health care transition, oral health; fields: all; need.9,10 Only one-third of pediatricians report making ade-
limits: within the last 10 years, humans, English, birth through quate referrals to adult physicians and fewer than 15 percent
age 18, young adult: 19-24 years. Additionally, websites for the provide appropriate educational materials to adolescents and
American Dental Association, American Medical Association, their parents. This is of concern for dental patients because
American Academy of Pediatric Dentistry, Agency for Health- adolescents who do not receive medical transitions are less
care Research and Quality, Special Care Dentistry Association, likely to receive dental transitions.11 Additional factors associ-
and International Association for Disability and Oral Health ated with limited access to care during adulthood transitioning
were reviewed. Expert opinions and best current practices include living in poverty and being a minority.12-14 There is
were relied upon when clinical evidence was not available. evidence that a proper handoff, including clear direct or
indirect communication between providers, reduces medical
Background errors during the transition.9 This transitioning period is
AAPD is aware of the challenges that SHCN patients and potentially stressful for parents and adolescents or young
their families encounter when seeking oral health care. As the adults with SHCN, and there is a paucity of resources for
prevalence of SHCN children has been increasing over the acquiring adulthood healthcare.15-17
past decades with advances in medical technology, the num- To improve health care transition for adolescents and
ber of young adults with chronic health conditions also has young adults with chronic conditions, a policy statement was
increased.2,3 It has been estimated that approximately 25 per-
cent of the 18 million U.S. young adults ages 18 to 21 who
should be transitioning to adult-centered care are affected by ABBREVIATIONS
at least one chronic health condition.4 Each year in the U.S., AAPD: American Academy Pediatric Dentistry. SHCN: Special health
750,000 adolescents with SHCN cross into adulthood, with care needs.
only 40 percent receiving attention to core transition issues.2,5

established by a number of medical organizations.12 The policy 6000 pediatric dentists. 24 The relatively small number and
statement articulated six critical steps to ensuring the success- distribution of pediatric dentists mean that broader involve-
ful transition to adult-oriented care. They are: ment by general dentists is necessary to address access to care
“1. to ensure that all young people with special health care issues, especially transition of patients with SHCN.25 When
needs have a health care provider who takes specific patients reach adulthood, their oral health care needs may go
responsibility for transition in the broader context of care beyond the scope of the pediatric dentist’s expertise. Even if
coordination and health care planning. a patient is best served by maintaining a dental home with
2. to identify the core competencies required by health care a pediatric dentist, he/she may require additional dental
providers to render developmentally appropriate health providers to manage some aspects of his/her oral health care.
care and health care transition, and ensure that the skills It may not be in the young adult’s best interest to be treated
are taught to primary care providers and are an integral solely in a pediatric facility.26
component of their certification requirements. Oral health care for adults with special needs is often diffi-
3. to develop a portable, accessible, medical summary to cult to access because of a lack of trained providers.3,25 A recent
facilitate the smooth collaboration and transfer of care survey revealed that most pediatric dentists help patients with
among and between health care professionals. SHCN transition into adult care, but the principal barrier is
4. to develop an up-to-date detailed written transition plan, the availability of general dentists and specialists willing to
in collaboration with young people and their families. accept these patients.27 A 2005 survey of senior dental students
5. to ensure that the same standards for primary and pre- noted that the provision of oral health care to patients with
ventive health care are applied to young people with special needs was among the top four topics in which they
chronic conditions as to their peers. were least prepared.28 This self-perceived lack of preparation
6. to ensure that affordable, comprehensive, continuous of future dentists bodes poorly for effective transitioning of
health insurance is available to young people with chronic adult SHCN patients.
health conditions throughout adolescence and into Addressing the manpower issue is of utmost importance.
adulthood.”8 Training and instruction for health care providers can be ob-
Although these steps represent a medical perspective, they tained through post-doctoral educational courses. Programs
may be applied to oral health care as well. such as general practice residencies and advanced education
It is important to educate and prepare the patient and in general dentistry provide opportunity for additional medi-
parent on the value of transitioning to a dentist who is knowl- cal, behavior guidance, and restorative training needed to treat
edgeable in adult oral health needs. At a time agreed upon by patients with SHCN. The Special Care Dentistry Association
the parent, patient, and pediatric dentist, the patient should fellowship and diplomate programs and Academy of General
be transitioned to a dentist knowledgeable and comfortable Dentistry’s mastership program also may provide opportunities
with managing the patient’s specific health care needs. In cases to increase the workforce.29-31
where this is not possible or desired, the dental home can Most patients with special needs can receive primary oral
remain with the pediatric dentist and referrals for specialized health care in traditional settings utilizing clinicians and sup-
dental care should be recommended when needed.18 port staff trained in accommodating these individuals. Others
Discussion about transition can begin early, although the require treatment by clinicians with more advanced training
transfer of care may not take place for many years. 3 There in special facilities.28 Some pediatric hospitals may enforce age
is evidence in support of initiating a transition plan between restrictions that can create a barrier to care for patients who
the 14 and 16 years of age.19 Anecdotal evidence suggests that have reached the age of majority.16 Hospitals frequently require
transition planning may be happening even earlier.6 that dentists eligible for medical staff membership be board
certified, thus making it difficult for general dentists to obtain
Barriers in transitioning patients with SHCN hospital privileges. While surgery centers abound, these may
Dentistry has been found to be the most common category of not be the preferred setting to treat medically compromised
unmet health care for children with special needs.20 Only 10 patients.
percent of surveyed general dentists reported that they treat Young adults may be discontinued from their parents’ insur-
patients with SHCN often or very often, while 70 percent ance, providing a financial barrier to care. Additional barriers
reported that they rarely or never treat patients with SHCN.21 to dental transition include low socioeconomic background
Pediatric dentists appear more likely to provide dental care and insufficient health insurance benefits.11
for this population as evidenced by a survey of AAPD mem- For patients with special needs, overall health care involves
bers which reported that 95 percent routinely treat patients intensive and ongoing medical supervision and coordination
with SHCN.22 between medical and dental care. The integration of dentistry
According to the 2011/2012 National Survey of Children within the medical care system presents a series of logistical
with Special Care Needs, there are approximately 14.6 million challenges.32 There is a lack of special programs or alternative
children with SHCN under 17 years of age (representing 19.8 care delivery arrangements (e.g., mobile dental programs,
percent of all U.S. children).23 The U.S. has approximately nursing home, group home facilities) to complement the care

provided through private practices to address access issues 3. Blum RW. Transition to adult care: Setting the stage. J
for patients with SHCN.33 Adolesc Health 1995;17(1):3-5.
The medical home34 reflects recognition that care is best 4. McPheeters M, Davis AM, Taylor JL, Brown RF, Potter
served by having a central point of contact for ongoing SA, Epstein RA, Jr. Transition Care for Children with
primary care and coordination of care when delivered by a Special Health Needs. Technical Brief No. 15 (Prepared
multitude of health care providers and support service pro- by the Vanderbilt University Evidence-based Practice
viders. The dental home1 closely parallels the essential elements Center under Contract No. 290-2012-00009-I). AHRQ
of the medical home as they relate to dental care.33 Publication No.14-EHC027-EF. Rockville, Md.: Agency
Linkages between patients’ medical and dental homes, for Healthcare Research and Quality; June 2014. Avail-
however, often are not established as formally as those among able at: “https://www.effectivehealthcare.ahrq.gov/ehc/
medical care providers, frequently resulting in inattention to products/546/1920/children-special-needs-transition-
dental services for patients with SHCN.35 Efforts to establish report-140617.pdf ”. Accessed June 29, 2016.
stronger relationships between medical and dental homes are 5. Scal P, Ireland M. Addressing transition to adult health
an important endeavor.36,37 care for adolescents with special health care needs.
The most efficient but least common arrangement of care Pediatrics 2005;115(6):1607-12.
for patients with SHCN is a single institution having pro- 6. American Academy of Pediatrics, American Academy of
viders from both disciplines (typically a hospital or regional Family Physicians, and American College of Physicians
care center).32 Transitioning may become less of an issue in Transitions Clinical Report Authoring Group. Supporting
these facilities; however, those with comprehensive dental the health care transition from adolescence to adulthood
clinics are limited in number and spread unevenly across the in the medical home. Pediatrics 2011;128(1):182-200.
country. 7. Koop CE. Executive summary. In: McGrab P, ed. Grow-
ing Up and Getting Medical Care: Youth with Special
Policy statement Health Care Needs. Jekyll Island, Ga.: U.S. Public Health
A coordinated transition from a pediatric-centered to an adult- Service; 1989.
centered dental home is critical for extending the level of oral 8. Rosen DS, Blum RW, Britto M, Sawyer SM, Siegle DM;
health and health trajectory established during childhood. Society for Adolescent Medicine. Transition to adult
The AAPD encourages: health care for adolescents and young adults with chronic
• expansion of the medical and dental home across the conditions: Position paper for the Society for Adolescent
life-span of a patient, especially to enable successful Medicine. J of Adolesc Health 2003;33(4):309-10.
transition of the adolescent with SHCN. 9. Starmer AJ, Spector ND, Srivastava R, et al. Changes in
• partnerships with other organizations to prepare gen- medical errors after implementation of a handoff program.
eral dentists to accommodate and provide primary health N Engl J Med 2014;372(5):490-1.
care for these patients in the usual dental setting. 10. Blum RW. Improving transition for adolescents with
• development of special programs or alternative care del- special health care needs from pediatric to adult-centered
ivery arrangements (e.g., mobile dental programs, nursing care. Pediatrics 2002;110(6 Pt 2):1301-3.
home, group home facilities) to complement the care 11. Chi DL. Medical care transition planning and dental
provided through private practices to address issues for care use for youth with special health care needs during
patients with SHCN. the transition from adolescence to young adulthood: A
• utilization of the six critical steps to maximize seamless preliminary explanatory model. Matern Child Health J
health care transition for the adolescent dental patient 2014;18(4):778-88.
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2. McManus MA, Pollack LR, Cooley WC, et al. Current 15. Arango P. Family-centered care. Acad Pediatr 2011;11
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ORAL HEALTH POLICIES: PATIENT SAFETY
Policy on Patient Safety

2018 patient safety. The Reference Manual of Pediatric Dentistry. Chicago,
Purpose possible sources of error in the dental office are miscom-

The American Academy of Pediatric Dentistry (AAPD) munication, interruptions, stress, fatigue, failure to review the
recognizes patient safety as an essential component of quality patient’s medical history (e.g., current medications, allergies),
oral health care for infants, children, adolescents, and those and lack of standardized records, abbreviations, and
with special health care needs. The AAPD encourages dentists processes.1,21,23 Treating the wrong patient or tooth/surgical
to consider thoughtfully the environment in which they deliver site, delay in treatment, disease progression after misdiagnosis,
health care services and to implement practices to improve inaccurate referral, incorrect medication dosage ordered/
patient safety. This policy is not intended to duplicate safety administered, breach in sterilization, and unintentional
recommendations for medical facilities accredited by national swallowing, aspiration, or retention of a foreign object are
commissions such as The Joint Commission or those related examples of patient safety events that occur in dentistry.24-28
to workplace safety such as Occupational Safety and Health Adverse events may be classified in terms of severity of harm
Administration. (e.g., none, mild, moderate, severe, death).29
Standardized processes and workflows help assure clerical
Methods and clinical personnel execute their responsibilities in a safe
This document is a revision of the policy developed by the and effective manner.23 Policy and procedure manuals that
Council on Clinical Affairs, adopted in 2008, and revised describe a facility’s established protocols serve as a valuable
in 2013. This policy is based on a review of current dental training tool for new employees and reinforce a consistent
and medical literature, including search of the PubMed /
MEDLINE database using the terms: patient safety AND
® approach to promote safe and quality patient care.23 Identi-
fying deviations from established protocols and studying
dentistry, fields: all; limits: within the last 10 years, humans, patterns of occurrence can help reduce the likelihood of
English. Eight hundred twenty-two articles met these criteria. adverse events.7
Papers for review were chosen from this list and from the Safety checklists are used by many industries and health-
references within selected articles. care organizations to reduce preventable errors.31,32 Data
supports the use of procedural checklists to minimize the
Background occurrence of adverse events in dentistry (e.g., presedation
All health care systems should be designed to provide a checklist).33-35 In addition, order sets, reminders, and clinical
practice environment that promotes patient safety.1 The guidelines built into an electronic charting system may im-
World Health Organization (WHO) defines patient safety as prove adherence to best practices.28
“the reduction of risk of unnecessary harm associated with Reducing clinical errors requires a careful examination of
healthcare to an acceptable minimum.”2 The most important adverse events23,28,30 and near-miss events22,36. In a near-miss
challenge in the field of patient safety is prevention of harm, event, an error was committed, but the patient did not ex-
particularly avoidable harm, to patients during treatment and perience clinical harm.22,36 Detection of errors and problems
care.2 Dental practices must be in compliance with federal within a practice or organization may be used as teaching
laws that help protect patients from preventable injuries and points to motivate changes and avoid recurrence.37 A root
potential dangers such as the transmission of disease.3-5 Laws cause analysis can be conducted to determine causal factors
help regulate hazards related to chemical and environmental and corrective actions so these types of events may be avoided
factors (e.g., spills, radiation) and facilities (e.g., fire prevention in the future.31,38,39 Embracing a patient safety culture demands
systems, emergency exits).6 The AAPD’s recommendations and a non-punitive or no-blame environment that encourages all
oral health policies provide additional information regarding personnel to report errors and intervene in matters of patient
the delivery of safe pediatric dental care.7-18 Furthermore, state safety.22,38 Alternatively, a fair and just culture is one that
dental practice acts and hospital credentialing committees are learns and improves by openly identifying and examining its
intended to ensure the safety of patients and the trust of
the public by regulating the competency of and provision of
services by dental health professionals.19-21 ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. WHO: World
Patient-centered health care systems that focus on pre- Health Organization.
venting errors are critical to assuring patient safety.21,22 Some

own weaknesses; individuals know that they are accountable • accuracy of patient identification with the use of at
for their actions but will not be blamed for system faults least two patient identifiers, such as name and date of
in their work environment beyond their control.39 Evidence- birth, when providing care, treatment, or services.
based systems have been designed for healthcare professionals • an accurate and complete patient chart that can be
to improve team awareness, clarify roles and responsibilities, interpreted by a knowledgeable third party.13 Standard-
resolve conflicts, improve information sharing, and eliminate izing abbreviations, acronyms, and symbols throughout
barriers to patient safety.40-42 the record is recommended.
The environment in which dental care is delivered impacts • an accurate, comprehensive, and up-to-date medical/
patient safety. In addition to structural issues regulated by dental history including medications and allergy list to
state and local laws, other design features should be planned ensure patient safety during each visit. Ongoing com-
and periodically evaluated for patient safety, especially as they munication with health care providers, both medical
apply to young children. Play structures, games, and toys are and dental, who manage the child’s health helps ensure
possible sources for accidents and infection.43,44 comprehensive, coordinated care of each patient.
The dental patient would benefit from a practitioner who • a pause or time out with dental team members present
follows current literature and participates in professional before invasive procedure(s) to confirm the patient,
continuing education courses to increase awareness and planned procedure(s), and tooth/surgical site(s) are
knowledge of best current practices. Scientific knowledge and correct.
technology continually advance, and patterns of care evolve • appropriate staffing and supervision of patients treated
due, in part, to recommendations by organizations with in the dental office.
recognized professional expertise and stature, including the • adherence to AAPD recommendations on behavior
American Dental Association, The Joint Commission, WHO, guidance, especially as they pertain to use of advanced
Institute for Health Improvement, and Agency for Health- behavior guidance techniques (i.e., protective stabili-
care Research and Quality. Data-driven solutions are possible zation, sedation, general anesthesia).
through documenting, recording, reporting, and analyzing • standardization and consistency of processes within
patient safety events.26,46,47 Continuous quality improvement the practice. A policies and procedures manual, with
efforts including outcome measure analysis to improve patient ongoing review and revision, could help increase em-
safety should be implemented into practices.28,45 Patient safety ployee awareness and decrease the likelihood of un-
incident disclosure is lower in dentistry compared with medicine toward events. Dentists should emphasize procedural
since a dental-specific reporting system does not exist in the protocols that protect the patient’s airway (e.g., rubber
United States.47 Identifiable patient information that is col- dam isolation), guard against unintended retained
lected for analysis is considered protected under the Health foreign objects (e.g., surgical counts; observation of
Insurance Portability and Accountability Act (HIPAA).48,49 placement/removal of throat packs, retraction cords,
cotton pellets, and orthodontic separators), and mini-
Policy statement mize opportunity for iatrogenic injury during delivery
To promote patient safety, the AAPD encourages: of care (e.g., protective eyewear).
• patient safety instruction in dental curricula to promote • minimizing exposure to nitrous oxide by maintaining
safe, patient-centered care. the lowest practical levels in the dental environment.
• professional continuing education by all licensed den- This includes routine inspection and maintenance of
tal professionals to maintain familiarity with current nitrous oxide delivery equipment as well as adherence
regulations, technology, and clinical practices. to clinical recommendations for patient selection and
• compliance and recognition of the importance of in- delivery of inhalation agents.
fection control policies, procedures, and practices in • minimizing radiation exposure through adherence to
dental health care settings in order to prevent disease as low as reasonably achievable (ALARA) principle,
transmission from patient to care provider, from care equipment inspection and maintenance, and patient
provider to patient, and from patient to patient.2-4 selection criteria.
• routine inspection of physical facility in regards to • all facilities performing sedation for diagnostic and
patient safety. This includes development and periodic therapeutic procedures to maintain records that track
review of office emergency and fire safety protocols adverse events. Such events then can be examined
and routine inspection and maintenance of clinical for assessment of risk reduction and improvement in
equipment. patient safety.
• recognition that informed consent by the parent is • dentists who utilize in-office anesthesia providers take
essential in the delivery of health care and effective all necessary measures to minimize risk to patients. Prior
relationship/communication practices can help avoid to delivery of sedation/general anesthesia, appropriate
problems and adverse events. The parent should under- documentation shall address rationale for sedation/
stand and be actively engaged in the planned treatment. general anesthesia, informed consent, instructions to

parent, dietary precautions, preoperative health evalua- 8. American Academy of Pediatric Dentistry. Use of nitrous
tion, and any prescriptions along with the instructions oxide for pediatric dental patients. Pediatr Dent 2018;
given for their use. Rescue equipment should have 40(6):281-6.
regular safety and function testing and medications 9. American Academy of Pediatric Dentistry. Prescribing
should not be expired. The dentist and anesthesia dental radiographs for infants, children, adolescents, and
providers must communicate during treatment to share individuals with special health care needs. Pediatr Dent
concerns about the airway or other details of patient 2017;39(6):205-7.
safety. 10. American Academy of Pediatric Dentistry. Behavior
• ongoing quality improvement strategies and routine guidance for the pediatric dental patient. Pediatr Dent
assessment of risk, adverse events, and near misses. A 2017;39(6):246-59.
plan for improvement in patient safety and satisfaction 11. American Academy of Pediatric Dentistry. Protective
is imperative for such strategies.5,6 stabilization for pediatric dental patients. Pediatr Dent
• comprehensive review and documentation of indica- 2017;39(6):260-5.
tion for medication order/administration. This includes 12. American Academy of Pediatric Dentistry. Informed
a review of current medications, allergies, drug inter- consent. Pediatr Dent 2017;39(6):397-9.
actions, and correct calculation of dosage. 13. American Academy of Pediatric Dentistry. Monitoring
• promoting a culture where staff members are empowered and management of pediatric patients before, during, and
and encouraged to speak up or intervene in matters of after sedation for diagnostic and therapeutic procedures:
patient safety. Update 2016. Pediatr Dent 2017;39(6):278-307.
14. American Academy of Pediatric Dentistry. Use of anes-
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ORAL HEALTH POLICIES: SELECTING ANESTHESIA PROVIDERS
Policy for Selecting Anesthesia Providers for the

Delivery of Office-Based Deep Sedation / General
Anesthesia
Adopted How to Cite: American Academy of Pediatric Dentistry. Policy for
2018 selecting anesthesia providers for the delivery of office-based deep
sedation/general anesthesia. The Reference Manual of Pediatric
2020:160-2.
Purpose No other responsibility is more important than identifying

The American Academy of Pediatric Dentistry (AAPD) an anesthesia provider who is highly competent. Significant
recognizes that it is the exclusive responsibility of dental prac- pediatric training, including anesthesia care of the very young,
titioners when employing anesthesia providers to administer and experience in a dental setting are important considerations,
office-based deep sedation/general anesthesia (DS/GA) to especially when caring for young pediatric and special needs
verify and carefully review the credentials and experience of populations. Advanced training in recognition and manage-
those providers.1 An understanding of the educational and ment of pediatric emergencies is critical in providing safe
training requirements of the various anesthesia professions sedation and anesthetic care.1 Close collaboration between the
and candid discussions with potential anesthesia providers can dentist and the anesthesia providers can provide access to care,
assist in the vetting and selection of highly skilled licensed establish an enhanced level of patient cooperation, improve
providers in order to help minimize risk to patients. surgical quality, and offer an elevated level of patient safety
during the delivery of dental care.
Methods Federal, state, and local credentialing and licensure laws,
This policy was developed by the Council on Clinical Affairs, regulations, and codes dictate who legally can provide office-
and is based on a review of current dental and medical based anesthesia services. Practitioners choosing to use these
literature pertaining to the education and training accredita- modalities must be familiar with the regulatory and professional
tion requirements of potential anesthesia providers. requirements needed to provide this level of pharmacologic
behavior management.1 The operating dentist must confirm
Background any potential anesthesia provider’s compliance with all licen-
Historically, care necessitating DS/GA was provided in a sure and regulatory requirements. Additional considerations in
surgical center or hospital-based setting by an anesthesiologist anesthesia provider selection may include proof of liability
selected and vetted by the facility or institution. The dental insurance and recommendations from professional colleagues.
surgeon had little, if any, choice as to who would provide Lastly, dentists must recognize potential liability issues associ-
these services. Current trends find an increasing number of ated with the delivery of DS/GA within their office.
dental providers electing to complete such care in the confines It is important to acknowledge that not all anesthesia pro-
of their office using the services of an anesthesia provider.2 viders have equal training and experience delivering care during
Over the last decade, office-based DS/GA in the dental office procedures performed within and around the oral cavity,
has proven to be safe and effective when delivered by a especially in the pediatric or special healthcare needs patient
highly competent and attentive individual.3 Substantial societal populations or on a mobile basis. The following table sum-
cost savings associated with the delivery of care outside of a marizes the educational requirements of various anesthesia
surgical center or hospital setting have been well documented.4 professions.
With the use of office-based DS/GA, the primary dental Because of the diversity in anesthesia education among po-
provider takes on the significant responsibility of creating a tential providers, operating dentists should further investigate
team of highly qualified professionals to deliver care in an an individual’s training and experience. A candid discussion
optimal and safe fashion. DS/GA techniques in the dental
office require at least three individuals:
• independently practicing and currently licensed anesthesia ABBREVIATION
provider. AAPD: American Academy Pediatric Dentistry. DS/GA: Deep
• operating dentist. sedation/general anesthesia. OMFS: Oral and maxillofacial surgery.
• support personnel.1

Table. ANESTHESIA EDUCATION AND TRAINING COMPARISON

Anesthesia provider Permitted to Minimum Min. # of Min. # of Definition Min. # of National examination/
function duration of DS/GA pediatric of pediatric DS/GA cases certification organization
independent of program cases cases patient involving
supervision by required for patients
anesthesiologist certification with SHCN
Certified No 24 months 400 GA cases 50 0-18 N/A National Commission for

anesthesiologist Certification of
assistant 5 Anesthesiologist Assistants
Certified registered In some states 24 months 25/400 < 2 yrs: 10 ≤12 yrs N/A National Board of
nurse anesthetist 6 Certification and
2-12 yrs: 30 Recertification for Nurse
Anesthetists
Dentist N/A 36 months 800 125 ≤7 yrs 75 American Dental Board
anesthesiologist 7 Anesthesiology and/or
National Dental Board
of Anesthesiology
Medical N/A 48 months N/A 100 ≤12 yrs N/A American Board of
anesthesiologist 8 Anesthesiology
Pediatric medical N/A 12 month- N/A N/A N/A N/A American Board of
anesthesiologist 9 fellowship Anesthesiology
following medical (Pediatric Anesthesiology
anesthesiology Examination10)
residency
Oral and N/A Five months 300 50 ≤18 yrs N/A National Dental Board
maxillofacial anesthesia service of Anesthesiology for
surgeon11 supplemented by anesthesia certification
OMFS service
48 months American Board of Oral
and Maxillofacial Surgery
for surgery certification
DS/GA= Deep sedation/General anesthesia. SHCN= Special health care needs. OMFS= Oral and maxillofacial surgery.
* During the oral and maxillofacial surgery training program, a resident’s assignment to the department of anesthesiology “must be for a minimum of five months,
should be consecutive and one of these months should be dedicated to pediatric anesthesia”.11 This anesthesia experience is supplemented throughout the
training program to ensure competence in deep sedation/general anesthesia on adult and pediatric patients.
with a potential anesthesia provider to establish the individual’s provider in a candid discussion to determine expectations,
comfort and experience with unique patient populations practices, and protocols to minimize risk for patients. Sample
(e.g., patients with development disabilities or medical questions to assist in this conversation appear below.
comorbidities, infants and toddlers) is extremely important,
especially if it is anticipated that this will represent a large Sample questions to ask a potential office-based anesthesia
portion of a dental practice’s DS/GA focus. Selection of a provider *
skilled and knowledgeable anesthesia provider is paramount in 1. What is your experience with pediatric patient popu-
providing patients with the safest and most effective care possible. lations? …special healthcare needs populations?
2. What is your background/experience in providing
Policy statement office-based DS/GA care? …and specifically for pediat-
The AAPD encourages dental practitioners when employing ric dental patients?
anesthesia providers to administer office-based DS/GA to 3. How do you evaluate a dental facility and staff prior
verify and carefully review the credentials and experience of to initiating anesthesia services? What expectations and
those providers. In addition to the credentialing process, the requirements do you have for the dentist, auxiliary
AAPD encourages dentists to engage a potential anesthesia staff, and facility?
* The information included in the preceding sample questions, developed by the AAPD, is provided as a tool for pediatric dentists and other dentists treating children.
It was developed by experts in pediatric dentistry and is offered to facilitate excellence in practice. However, these samples do not establish a standard of care. In
issuing this information, the AAPD is not engaged in rendering legal or other professional advice. If such services are required, competent legal or other professional
counsel should be sought.

4. What equipment do you use to administer and moni- 4. Rashewsky S, Parameswaran A, Sloane C, et al. Time and
tor DS/GA in the office, and what is your maintenance cost analysis: Pediatric dental rehabilitation with general
protocol for this equipment? anesthesia in the office and the hospital settings. Anesth
5. What equipment and/or medications should be Prog 2012;59(4):147-58.
maintained by the dental facility? 5. Commission on Accreditation of Allied Health Edu-
6. What are some potential emergencies associated with cation Programs. Standards and Guidelines for the
the delivery of DS/GA in the pediatric dental office, Accreditation of Educational Programs for the Anesthe-
noting any that may be unique to these clinical siologist Assistant, Revised 2016. Available at: “https://
circumstances? www.caahep.org/CAAHEP/media/CAAHEP-Documents/
7. What is your training/experience in recognition and StandardsAnesthesiologistAssistant.pdf ”. Accessed
8.
management of pediatric anesthetic emergencies?
In the event of a medical emergency, what is your www.webcitation.org/722mS5XuN”)
®
February 14, 2018. (Archived by WebCite at: “http://
plan of action? What are the roles of the dentist and 6. Council on Accreditation of Nurse Anesthesia Educational
auxiliary staff during a medical emergency? Programs. Standards for Accreditation of Nurse Anesthe-
9. Do you have an affiliation with any area hospitals in sia Educational Programs, Revised January, 2018.
case a patient requires transfer? Available at: “http://home.coa.us.com/accreditation/
10. What patient selection criteria (e.g., age, weight, co- Documents/2004%20Standards%20for%20Accreditation
morbidities) do you use to identify potential candidates %20of%20Nurse%20Anesthesia%20Educational%20
for office-based DS/GA? Programs,%20revised%20January%202018.pdf ”. Accessed
11. When a decision has been made that a patient is a
candidate for office-based sedation/general anesthesia, //www.webcitation.org/722mNYvtX”)
®
February 14, 2018. (Archived by WebCite at: “http:
what is the office’s role in preparing a patient for 7. Commission on Dental Accreditation. Accreditation
office-based DS/GA? How and when do you prepare Standards for Advanced General Dentistry Education
the patient for the procedure? in Dental Anesthesiology, 2017. Available at: “https://
12. What is your protocol for monitoring a patient www.ada.org/~/media/CODA/Files/2018_Dental_
post-operatively? Anesthesiology_Standards.pdf?la=en”. Accessed February
13. What are your discharge criteria and your follow-up
protocols for patients who receive office-based DS/ webcitation.org/722mCtzH0”)
®
14, 2018. (Archived by WebCite at: “ http://www.
GA? 8. Accreditation Council for Graduate Medical Education.

14. Would you describe a typical general anesthesia case ACGME Program Requirements for Graduate Education
from start to finish? in Anesthesiology, July 1, 2017. Available at: “https://
15. What is your protocol for ordering, storing, and www.acgme.org/Portals/0/PFAssets/ProgramRequirements/
recording controlled substances for DS/GA cases? 110_emergency_medicine_2017-07-01.pdf ”. Accessed
16. What are the patient fees associated with office-based
DS/GA services? www.webcitation.org/722m1xDAm”)
®
February 14, 2018. (Archived by WebCite at: “http://
17. How and where are patients records related to the 9. Accreditation Council for Graduate Medical Education.
office-based administration of and recovery from DS/ ACGME Program Requirements for Graduate Medical
GA stored? Education in Pediatric Anesthesiology. July 1, 2017.
Available at: “https://www.acgme.org/Portals/0/PFAssets
References /ProgramRequirements/042_pediatric_anesthesiology
1. American Academy of Pediatric Dentistry. Use of anes- _2017-07-01.pdf?ver=2017-06-28-085120-903”. Accessed
thesia providers in the administration of office-based
deep sedation/general anesthesia to the pediatric dental www.webcitation.org/722lp4RSQ”)
®
June 13, 2018. (Archived by WebCite at: “ http://
patient. Pediatr Dent 2018;40(6):317-20. 10. American Board of Anesthesiology. Pediatric anesthe-
2. Saxen MA, Urman RD, Yepes JF, Gabriel RA, Jones siology registration eligibility. Available at: “http://www.
JE. Comparison of anesthesia for dental/oral surgery by theaba.org/Exams/Pediatric-Anesthesiology/Registration
office-based dentist anesthesiologists versus operating -Eligibility”. Accessed June 13, 2018. (Archived by
room-based physician anesthesiologists. Anesth Prog
2018;64(4):212-20.
®
WebCite at: “http://www.webcitation.org/722lew6YX”)
11. Commission on Dental Accreditation. Accreditation
3. Spera AL, Saxen MA, Yepes JF, Jones JE, Sanders BJ. Standards for Advanced Specialty Educational Programs
Office-based anesthesia: safety and outcomes in pedi- in Oral and Maxillofacial Surgery, 2017. Available at:
atric dental patients. Anesth Prog 2017;64(3):144-52. “https://www.ada.org/~/media/CODA/Files/oms.pdf?la=en”.
Accessed February 14, 2018. (Archived by WebCite at:
“http://www.webcitation.org/722lTtH4K”)
®

ORAL HEALTH POLICIES: ETHICAL RESPONSIBILITIES IN OHC MANAGEMENT
Policy for the Ethical Responsibilities in the Oral

Health Care Management of Infants, Children,
Adolescents, and Individuals with Special Health
Care Needs
2020 the ethical responsibilities in the oral health care management of
infants, children, adolescents, and individuals with special health
care needs. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
Purpose Oral health care practitioners may offer services for children
The American Academy of Pediatric Dentistry (AAPD) believes and individuals with SHCN in a variety of settings (e.g., solo
that all infants, children, adolescents, and individuals with practice, general dentistry group practice, specialty group
special health care needs (SHCN) are entitled to oral health practice, dental service organization, educational institution,
care that meets the treatment and ethical standards set by our hospital, public health or military clinic). Although each
specialty. entity will have its own administrative policies and procedures
to which practitioners must adhere, each provider also must
Methods be aware of and follow established standards and evidence-
This policy was developed by the Council on Clinical based guidelines promulgated by organizations with recognized
Affairs and adopted in 2003.1 This document is a revision of professional expertise and stature.
the previous version, revised in 2015.2 Dentists are held responsible for their clinical and ethical
decisions regardless of who holds the responsibility for busi-
Background ness decisions.7 The “ultimate responsibility for compliance
Dentists have an obligation to act in an ethical manner in the with state laws and regulations falls upon the practicing
care of patients with consideration of the virtues of ethics licensed dentist.”8 All patients must receive dental care con-
including autonomy, beneficence, nonmaleficence, and justice. sistent with the moral, ethical, and evidence-based standards
Autonomy reflects the patient’s or, when the patient is a of care regardless of the care setting. The treating doctor’s
minor or an intellectually disabled adult who lacks capacity to clinical judgment should not be influenced by financial
give consent, the parent’s3 or guardian’s right to be involved in considerations of the business entity.
treatment decisions. The caregiver must be informed of the Patients/parents need to play an active role in decision
problem and that treatment is recommended. Beneficence in- making with their doctors and must be informed about their
dicates the dentist has the obligation to act for the benefit of medical and dental problems and treatment options. 4
the patient in a timely manner even when there may be con- Evidence-based knowledge and treatment options are evolving
flicts with the dentist’s personal self interests. Nonmaleficence at a rapid pace. As a result, patients/parents and health care
dictates that the dentist’s care does not result in harm to the providers are seeking second opinions so that more informed
patient. In situations where a dentist is not able to meet the decisions based on the risks and benefits can be made for treat-
patient’s needs, referral to a practitioner capable of providing ment. A provider has an ethical obligation, subject to privacy
the needed care is indicated. Justice expresses that the dentist regulations, on request of either the patient or the patient’s new
should deal fairly with patients, colleagues, and the public.4,5 provider to furnish records, including radiographs, or copies
Denial of care by the provider because of age, behavior, in- of them. These may be beneficial for the future treatment of
ability to cooperate, disability, or medical status can result in that patient.4 Health Insurance Portability and Accountability
unnecessary pain, discomfort, increased treatment needs and Act (HIPAA) privacy rules9 and state laws apply to all exchanges
costs, unfavorable treatment experiences, and diminished oral
health outcomes. If a dentist is unable to provide medically-
necessary care6, he has an ethical responsibility to refer the ABBREVIATIONS
patient to a practitioner or facility capable of providing AAPD: American Academy Pediatric Dentistry. SHCN: Special
the care. health care needs.

ORAL HEALTH POLICIES: ETHICAL RESPONSIBILITIES IN OHC MANAGEMENT
of health care information. Educating the patient/parent 3. American Academy of Pediatric Dentistry. Overview:
regarding the diagnosis and available treatment options, in- Definition of parent. The Reference Manual of Pediatric
cluding their risks and benefits, should be the goal of a second Dentistry. Chicago, Ill.: American Academy of Pediatric
opinion consultation. Health care providers may disagree on Dentistry; 2020:8.
the best treatment for an individual patient. Any opinion 4. American Dental Association. Principles of Ethics and
should be rendered only after careful consideration of all the Code of Professional Conduct. With official advisory
facts and with due attention given to current and previous opinions revised to November 2018. Available at: “https:
health status of the patient. When presented with requests //www.ada.org/~/media/ADA/Member%20Center/
for second opinions, practitioners should consider the legal Ethics/Code_Of_Ethics_Book_With_Advisory_Opinions
implications of such requests. Health care providers rendering _Revised_to_November_2018.pdf?la=en”. Accessed
second opinions unwarily could be involved in litigation, September 14, 2020.
either on behalf of the patient or in defending themselves 5. American College of Dentists. Ethics Handbook for Den-
against other practitioners as a result of the consult. The fact tists. Introduction to Ethics, Professionalism, and Ethical
that one is the second or third consulted professional does Decision Making. Gaithersburg, Md.: American College
not mean that the provider is exempt from liability.10 Parents of Dentists; 2016. Available at: “https://www.acd.org/
and patients should be fully advised of their health status publications-2/ethics-handbook/”. Accessed September
without disparaging comments about their prior treatment 14, 2020.
or previous provider. 6. American Academy of Pediatric Dentistry. Definition of
medically-necessary care. The Reference Manual of
Policy statement Pediatric Dentistry. Chicago, Ill.: American Academy of
Infants and children through adolescence, including those with Pediatric Dentistry; 2020:18.
special health care needs, have a right to dental care. The AAPD 7. Academy of General Dentistry Practice Models Task Force.
believes it is unethical for a dentist to ignore a disease or Investigative Report on the Corporate Practice of Dentis-
condition because of the patient’s age, behavior, or disabilities. try, 2013. Chicago, Ill.: Academy of General Dentistry.
Dentists have an ethical obligation to provide therapy for Available at: “https://www.agd.org/docs/default-source/
patients with oral disease or refer for treatment patients whose advocacy-papers/agd-white-paper-investigate-report-on
needs are beyond the skills of the practitioner. -corporate-dentistry.pdf?sfvrsn=c0d75b1_2”. Accessed
The AAPD encourages all entities and practitioners who September 14, 2020.
provide oral health care services to children to follow evidence- 8. Association of Dental Support Organizations, Dentists for
based clinical practice guidelines and best practices developed Oral Health Innovation, Waller. Toward a common goal:
by organizations with recognized professional expertise and The role of dental support organizations in an evolving
stature. Under no circumstance should the business or cor- profession. July 1, 2014. Dentists for Oral Health Inno-
porate entity interfere with the clinical judgment of the vation, Waller, contributors. Available at: “https://www.
treating dentist. dentalonejobs.com/wp-content/uploads/2017/02/ADSO
A patient/parent has a right to a second opinion. A provider -White-Paper.pdf ”. Accessed July 21, 2020.
who is trained and experienced in diagnosing and treating the 9. U.S. Department of Health and Human Services. Health
condition is encouraged to provide the second opinion. When Information Privacy: The HIPAA privacy rule. Available
presented with requests for second opinions, practitioners must at: “https://www.hhs.gov/hipaa/for-professionals/privacy/
consider the legal implications of such requests. Patients/parents index.html#:~:text=The%20HIPAA%20Privacy%20
should be fully advised of their health status without disparaging Rule%20establishes,certain%20health%20care%20
comments about their prior treatment or previous provider. transactions%20electronically”. Accessed July 21, 2020.
The AAPD advocates legislation or regulation at the federal 10. Machen DE. Legal aspects of orthodontic practice: Risk
and state levels to ensure that dentists are free to exercise management concepts. Am J Orthod Dentofacial Orthop
individual professional clinical judgment and render appro- 1990;937(3):269-70.
priate treatment to their patients without undue influence or 11. American Dental Association. Dentist’s freedom to exercise
infringement by any third-party business and entity.11,12 individual clinical judgment (Trans.1997:705). Current
Policies 2018:177. Chicago, Ill.: American Dental Asso-
References ciation; 2018. Available at: “https://www.ada.org/~/media
1. American Academy of Pediatric Dentistry. Policy on the /ADA/Member%20Center/Members/current_policies.
ethics of failure to treat or refer. Pediatr Dent 2003;25 pdf?la=en”. Accessed September 26, 2019 .
(Suppl):49. 12. American Dental Association. Statement Regarding Em-
2. American Academy of Pediatric Dentistry. Policy on the ployment of a Dentist. (Trans.2013:353). Practice
ethical responsibilities in the oral health care management Administration. In: Current Policies Adopted 1954-2019.
of infants, children, adolescents, and individuals with Chicago, Ill.: American Dental Association; 2019:168 .
special health care needs. Pediatr Dent 2015;37(special Available at: “https://www.ada.org/~/media/ADA/Member
issue):114-5. %20Center/Members/current_policies.pdf?la=en”. Accessed
September 26, 2019.

ORAL HEALTH POLICIES: BILL OF RIGHTS AND RESPONSIBILITIES
Policy on a Patient’s Bill of Rights and Responsibilities

2019 a patient’s bill of rights and responsibilities. The Reference Manual
Purpose certain responsibilities. As such, the AAPD proposes this

The American Academy of Pediatric Dentistry (AAPD) Policy on a Patient’s Bill of Rights and Responsibilities in the
recognizes that pediatric oral health care should be rendered planning and delivery of pediatric oral health care.
under conditions acceptable to both patient and dentist. The
expectation is that oral health care providers, their staff, Policy statement
patients, and parents of patients will support this policy, The AAPD encourages oral health care providers to tailor
thereby enhancing patient care. this Bill of Rights and Responsibilities to their patient
community by translating and/or simplifying it as necessary
Methods to ensure that patients and their families understand their
This policy was developed by the Council on Clinical Affairs rights and responsibilities.3
and adopted in 2009. This document is based on electronic
database and hand searches of articles in medical and dental Patient rights
literature using the following parameters: terms: patient The patient has the right to:
freedoms, Patient’s Bill of Rights, Bill of Rights, Consumer • receive treatment at a dental home that provides
Bill of Rights; fields: all; limits: within the last 10 years, comprehensive, considerate, and respectful care;
English, and birth through age 18. Nineteen articles met these • have oral health diagnoses made by a dentist;
criteria. • know the identity, education, and training of providers
involved in his/her care, as well as when those involved
Background are students, residents, or other trainees;3
The AAPD is the leader in representing the oral health • choose an oral health care provider. The parent has a
interests of infants, children, adolescents, and persons with right to designate a pediatric dentist as a primary oral
special health care needs.1 Effective oral health care requires health care provider for the child;
collaboration between pediatric dentists, their patients/ • participate fully in all the decisions related to his/her care;
parents, and other health care professionals. Optimal patient • receive accurate, relevant, current, and easily understood in-
care requires open and honest communication between formation concerning diagnosis, treatment, and prognosis;
provider and patient, mutual respect for personal and • discuss and request information related to specific pro-
professional values, and sensitivity to differences.2 cedures and/or treatments, including accompanying risks
Often, the delivery of contemporary pediatric oral health and benefits, and the medically reasonable alternatives.
care can be confusing to parents. It is normal for parents to Life threatening emergency care could be an exception;
have expectations about their child’s proposed care. Yet, it • make decisions about the plan of care prior to and
is important that these parents have realistic expectations as during the course of treatment, to refuse a recommended
well as a clear understanding of their responsibilities in the treatment or plan of care to the extent permitted by law,
delivery of care to their children. and to be informed of the health consequences of this
A Patient’s Bill of Rights is a statement of the rights to refusal. In case of refusal, the patient is entitled to other
which patients are entitled as recipients of medical/dental appropriate care and services that the pediatric dentist
care. These rights can be exercised on the patient’s behalf offers or to transfer to another dentist;4
by a parent or legal guardian if the patient is a minor, lacks • consent to or decline to participate in proposed research
decision-making capacity, or is legally incompetent. It artic- studies affecting care and treatment or requiring direct
ulates the positive rights that health care providers and facil- patient involvement and to have those studies explained
ities should provide patients, thereby providing information, fully prior to consent. A patient who declines to partici-
offering fair treatment, and granting them autonomy over pate in research is entitled to the most effective care that
medical decisions. the pediatric dentist can otherwise provide;
The collaborative nature of health care requires that
patients, or their families/surrogates, participate in their care.
ABBREVIATION
The effectiveness of care and patient satisfaction with the AAPD: American Academy Pediatric Dentistry.
course of treatment depend, in part, on the patient’s fulfilling

ORAL HEALTH POLICIES: BILL OF RIGHTS AND RESPONSIBILITIES
• expect reasonable continuity of care; • being considerate of the rights of other patients and health
• emergency care as needed for acute dental trauma and care workers.6 This includes not interfering with the
odontogenic infections; functioning of the facility, avoiding profane or derogatory
• know the immediate and long-term financial implica- behavior, and minimizing noise;
tions of treatment choices, insofar as they are known by • his/her conduct with staff. The patient must resolve
the provider. The patient has the right to be informed of conflicts using available institutional mechanisms. Verbal
the charges for services and available payment methods; and physical abuse of staff is prohibited;7
• be informed of the provider’s policies and practices that • following Health Insurance Portability and Accountabil-
relate to patient care, treatment, and responsibilities. ity Act (HIPAA) guidelines including not taking videos/
This includes available resources for resolving disputes, photographs of people and/or protected health
grievances, and conflicts, such as ethics committees, information; and
patient representatives, or other mechanisms available in • providing accurate insurance information and for
an organization; accepting the financial obligations associated with the
• have privacy considered in every interaction. Case dis- services rendered.
cussion, consultation, examination, and treatment should
be conducted in a way that best protects each patient’s References
privacy; 1. American Academy of Pediatric Dentistry. Who is AAPD?
• advise staff regarding specific privacy concerns or Available at: “https://www.aapd.org/about/about-aapd/
questions;5 who-is-aapd/”. Accessed July 11, 2019.
• expect that all communications and records pertaining 2. American Hospital Association. Patient care partnership,
to his/her care will be treated as confidential, except in Understanding expectations, rights and responsibilities.
cases where reporting is permitted or required by law Available at: “https://www.aha.org/system/files/2018-01/
(e.g., suspected abuse, public health hazards). The aha-patient-care-partnership.pdf ”. Accessed July 11, 2019.
patient has the right to expect that the provider will 3. Kaiser Permanente. Your rights and responsibilities South-
emphasize the confidentiality of information released to ern, California. Available at: “https://m.kp.org/health/
other parties entitled to review this information; care/consumer/center/!ut/p/a1/hZBPT4QwEMU_yx4
• review the records pertaining to his/her medical care and 4QgcI_7wBLhtAxc0aF3sxQCo0lpa0dYnfXmDjwUTjJ
to have the information explained or interpreted as JPMJG9-efMQRjXCvLnQvtFU8IatO_Zfs-JUJYkdQ-
necessary, except when restricted by law. The patient has VVHuT33iEq_AcH0gCdUYFwz0S7iV8GracbAwyYp6k-
the right to request amendments to his/her record; and TXBOuu6WJNADhRmraMYLqIEqSGBLfDNPs1rTt-
• ask and be informed of the existence of business rela- vWNGkKVmGKZ-5kV2sHfTf2nXiTfjApS0H7QyJVG-
tionships among institutions, other health care providers, T4Iq2lFFNiVoZMW_dsEdYkjciibQ-5GJ0BasreZ6tXoi-
or payors that may influence the patient’s treatment and eEasT48L95WQQSqP6p3J5HG_ZgJsft2wOjz5AHpZ-
care. P5XNUugDOt-CPigFNY_jpsssdOZvvx3i3-wLRPKsu/dl5/
d5/L2dBISEvZ0FBIS9nQSEh/”. Updated March 2014.
Patient responsibilities Accessed July 11, 2019.
These responsibilities can be exercised on the patient’s behalf 4. University of Pittsburgh Medical Center (UPMC).
by a parent or legal guardian if the patient is a minor, lacks Patient rights and responsibilities at UPMC Hospitals.
decision-making capacity, or is legally incompetent. The patient Updated 2019. Available at: “https://www.upmc.com/
is responsible for: patients-visitors/patient-info/rights-and-responsibilities”.
• providing, to the best of his/her knowledge, accurate and Accessed July 11, 2019.
complete information about past illnesses, hospitaliza- 5. Vanderbilt Health. Patient rights and responsibilities.
tions, medications, and other matters related to his/her Vanderbilt Health. Available at: “https://vanderbilthealth.
health status; com/comprehensivecare/30764”. Published March 25,
• requesting additional information or clarification about 2004. Accessed July 11, 2019.
his/her health status or treatment when he/she does not 6. PeaceHealth St. Joseph Medical Center. Patient rights
fully understand information and instructions; and responsibilities. Available at: “https://www.peace
• his/her actions if he/she refuses treatment or does not health.org/sites/default/files/patient-rights-english_0.pdf ”.
follow the instructions of the provider.3 It is the patient’s Published 2018. Accessed July 11, 2019.
responsibility to inform dentists and other caregivers of 7. Mayo Clinic. Rights and responsibilities of patients.
anticipated problems in following prescribed treatment, Available at: “https://www.mayoclinic.org/documents/
including follow-up treatment instructions; mcj6256-pdf/doc-20079310”. Published 2008. Accessed
• keeping appointments and, when unable to do so, July 11, 2019.
notifying the dental office as soon as possible;

ORAL HEALTH POLICIES: DENTAL STEM CELLS
Policy on Using Harvested Dental Stem Cells

2017 using harvested dental stem cells. The Reference Manual of
Purpose related to oral health care have included wound healing and
The American Academy of Pediatric Dentistry recognizes regeneration of dental and periodontal tissues as well as
the emerging field of regenerative medicine and encourages craniofacial structures (e.g., repair of cleft lip/palate).7
dentists to follow evidence-based literature in order to educate Parents may elect to preserve umbilical cord blood of their
parents about the collection, storage, viability, and use child for future harvesting of stem cells if autologous regen-
of dental stem cells with respect to autologous regenerative erative therapies are indicated. Pulpal tissue of exfoliating
therapies. The American Academy of Pediatric Dentistry also primary teeth, oral mucosa fibroblasts, 8 surgically removed
recognizes that harvested dental stem cells is an emerging third molars, periodontal ligament,9 and gingival fibroblasts9
science which may have application for oral health care but may serve as a source of mesenchymal stem cells.2,10
at present there are no treatments available using harvested The public is increasingly aware of this emerging science,
dental stem cells in humans. This policy is related to the use and more parents are expressing interest in harvesting/banking
of harvested dental stem cells from a tooth or follicle. This dental stem cells. While sources of dental stem cells are read-
policy does not include stem cells which are intrinsically ily accessible, those cells must be secured and stored properly
present for treatment related to regenerative endodontics from to maintain the potential to proliferate and differentiate. 11,12
the apical papilla or dental pulp cells. Stem cells used for Additionally, harvested dental stem cells currently are not very
regenerative endodontics and scaffolding have evidenced-based stable and have been known to form tumors in vivo.2 More
literature to show successful regeneration.1-3 studies are recommended to assess the safety and efficacy of
harvested dental stem cells prior to initiating human clinical
Methods trials.2
This policy was developed by the Council on Clinical Affairs
and adopted in 2010. This document is an update of the Policy statement
previous version, revised in 2013. This revision included a While there currently are no treatments available using
review of current dental and medical literature and sources harvested dental stem cells in humans, the American Academy
of recognized professional expertise related to dental stem of Pediatric Dentistry recognizes that this is an emerging
®
cells. A literature search of the PubMed /MEDLINE data-
base was conducted using the terms: dental stem cell, harvested
science which may have application for oral healthcare. As the
technology continues to evolve, the process of procurement
tooth cell; fields: all; limits: within the last 10 years, humans, of dental stems cells should be accomplished only with
English, birth through age 99. Thirty-one articles matched deliberate integrity and appropriate informed consent to assure
these criteria. Papers for review were chosen from this list the highest ethical standards and quality of outcomes.
and from the references within selected articles. Expert and/or
consensus opinion by experienced researchers and clinicians References
was also considered. 1. Conde MC, Chisini LA, Demarco FF, et al. Stem cell-
based pulp tissue engineering: Variables enrolled in
Background translation from the bench to the bedside, a systematic
Stem cells are pluripotential cells that can divide and multiply review of literature. Int Endod J 2016;49(6):543-50.
for an extended period of time, differentiating into a diverse 2. Hynes K, Menichanin D, Bright R, et al. Induced pluri-
range of specialized cell types and tissues. Adult mesenchymal potent stem cells: A new frontier for stem cells in
stem cells, of which dental stem cells are a subset, are highly dentistry. J Dent Res 2015;94(11):1508-15.
proliferative and have the ability to differentiate into many 3. Yang J, Yuan G, Chen Z. Pulp regeneration: Current
cell lines.4 The most familiar application of adult stem cell approaches and future challenges. Front Physiol 2016;
therapy is bone marrow transplantation to treat hematopoietic 7:58.
cancers, metabolic disorders, and congenital immunodeficiency 4. Govindasamy V, Ronald VS, Abdullah AN, et al. Differen-
syndromes. Stem cell therapy is undergoing clinical testing tiation of dental pulp stem cells into islet-like aggregates.
for other conditions such as Parkinson’s disease, diabetes, and J Dent Res 2011;90(5):626-52.
brain trauma/spinal cord injuries.5,6 Suggested applications

ORAL HEALTH POLICIES: DENTAL STEM CELLS
5. Kadar K, Kiraly M, Porcsalmy B, et al. Differentiation 10. Eslaminejad MB, Vahabi S, Shariati M, Nazarian H. In
potential of stem cells from human dental origin – vitro growth and characterization of stem cells from
Promise for tissue engineering. J Physiol Pharmacol 2009; human dental pulp of deciduous versus permanent teeth.
60(suppl 7):167-75. J Dent (Tehran) 2010;7(4):185-95.
6. Nourbakhsh N, Soleimani M, Taghipour Z, et al. 11. Perry BC, Zhou D, Wu X, et al. Collection, cryopreserva-
Induced in vitro differentiation of neural-like cells from tion, and characterization of human dental pulp-derived
human exfoliated deciduous teeth-derived stem cells. mesenchymal stem cells for banking and clinical use.
Int J Dev Biol 2011;55(2):189-95. Tissue Eng Part C Methods 2008;14(2):149-56.
7. Nishino Y, Yamada Y, Ebisawa K, et al. Stem cells from 12. Yildirim S, Zibandeh N, Genc D, Ozcan EM, Goker K,
human exfoliated deciduous teeth (SHED) enhance Akkoc T. The comparison of the immunologic properties
wound healing and the possibility of novel cell therapy. of stem cells isolated from human exfoliated deciduous
Cytotherapy 2011;13(5):598-605. teeth, dental pulp, and dental follicles. Stem Cells Int
8. Miyoshi K, Tsuji D, Kudoh K, et al. Generation of 2016;2016:4682875. Available at: “https://www.hind
human induced pluripotent stem cells from oral mucosa. awi.com/journals/sci/2016/4682875/”. Accessed June 9,
J Biosci Bioeng 2010;110(3):345-50.
9. Wada N, Wang B, Lin NH, Laslett AL, et al. Induced
®
citation.org/6tkJoR5zd”)
pluripotent stem cell lines derived from human gingival
fibroblasts and periodontal ligament fibroblasts. J
Periodontal Res 2011;46(4):438-47.

ORAL HEALTH POLICIES: INFECTION CONTROL
Policy on Infection Control

2020 infection control. The Reference Manual of Pediatric Dentistry.
Purpose combination of standard precautions, contact precautions, and

The American Academy of Pediatric Dentistry (AAPD) droplet precautions may be utilized when performing patient
recognizes the importance of infection control policies, pro- care.5,6
cedures, and practices in dental health care settings in order The possibility of contamination within the internal com-
to prevent disease transmission. ponents of dental handpieces has led to the recommendation4,6
that all dental handpieces, including low-speed motors and
Methods removable prophylaxis angles, undergo heat sterilization be-
This policy was developed by the Infectious Disease Control tween patients. Following instructions for sterilization provided
Subcommittee of the Clinical Affairs Committee and adopted by the manufacturer of reusable equipment can help ensure
in 1989.1 This document is a revision of the previous version, effectiveness of sterilization techniques3 and compliance with
revised in 2019.2 The revision of the policy is based upon a current standards4-6.
review of current dental and medical literature related to in- Infections associated with microbial transmission from
fection control, expert opinion, and best current practices. dental waterlines have been reported.7-12 To help prevent such
infections, it has been recommended that practitioners “follow
®
Literature searches of PubMed /MEDLINE and Google
Scholar databases were conducted using the terms: dentistry manufacturer guidelines to disinfect waterlines, monitor water
infection control AND health care and infection control AND quality to ensure recommended bacterial counts, use point-of-
dental; fields: all; limits: within the last 10 years, English, use water filters, and eliminate dead ends in plumbing where
humans, comparative study, meta-analysis, multicenter study, stagnant water can enable biofilm formation.”10 In 2015, an
systematic reviews, and validation study. The search returned outbreak of Mycobacterium abscessus odontogenic infections in
365 articles that matched the criteria. The articles were eval- children receiving pulpotomy treatment from a pediatric den-
uated by title and/or abstract and relevance to dental care for tal clinic was investigated.10 The source of the Mycobacterium
children and adolescents. Twenty articles were chosen from was contaminated water from dental unit waterlines.9-14 In
this method and from references within selected articles. California, 22 confirmed and over 70 suspected non-
immunocompromised pediatric dental patients had a diagnosis
Background of Mycobacterium abscessus odontogenic infections following
The application of standard precautions regarding infection pulpal therapy.8,9,14
control during dental treatment is paramount. The environ- Water from the dental operatory units is subject to the
ment in which dental care is delivered impacts both patient standard for safe drinking water set by the Environmental
and provider safety. Knowledge of current best practices in Protection Agency, the American Public Health Association,
infection control can help reduce exposure to and contamina- and the American Water Works Association.3 A water man-
tion risks from infectious materials. This would include body agement plan that includes routine maintenance procedures
substances, contaminated supplies, equipment, environmental for dental unit waterlines (according to the manufacturer’s
surfaces, water, and air. Some infection control practices rou- instructions) and monitoring water quality can help keep
tinely used by health-care professionals cannot be rigorously bacterial counts low.15 The CDC states “conventional dental
evaluated by clinical trials for ethical and logistical reasons.3 units cannot reliably deliver sterile water even when equipped
Many resources are available to aid dental providers in with independent water reservoirs containing sterile water
creating checklists, standard operating procedures, or other because the water-bearing pathway cannot be reliably sterilized.”16
quality assurance mechanisms for use in daily practice. The Sterile water and sterile saline have been recommended for use
Centers for Disease Control and Prevention (CDC)4,5 and the as a coolant or irrigant during oral surgical procedures.3,15,17
Occupational Safety and Health Administration (OSHA)6, as When a pulp exposure occurs and pulp therapy is indicated,
well as state and local regulatory boards or agencies and equip-
ment manufacturers, provide guidance for patient care,
ABBREVIATIONS
laboratory procedures, and equipment management. Such
AAPD: American Academy Pediatric Dentistry. CDC: Centers for
entities can serve as valuable sources for current infection Disease Control and Prevention. OSHA: Occupational Safety and
control recommendations. Until more is known about severe Health Administration. PPE: Personal protective equipment.
acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a

irrigants should not come from dental unit water lines. A References
single-use disposal syringe should be used to dispense irrigants 1. American Academy of Pediatric Dentistry. Guideline on
for pulpal therapy. infection control. Presented at: Annual Meeting of the
Although no adverse health effects have been reported American Academy of Pediatric Dentistry; May 1989;
with use of saliva ejectors, the CDC cautions dental health Orlando, Fla.
care providers to be aware of the possibility of suctioned 2. American Academy of Pediatric Dentistry. Policy on
fluids in tubing flowing back into the patient’s mouth.3 This infection control. The Reference Manual of Pediatric
can happen when: Dentistry. Chicago, Ill.: American Academy of Pediatric
1. the pressure in patient’s mouth, as a result of closing Dentistry; 2019:162-3.
their lips and forming a seal around the tip of the 3. Kohn WG, Collins AS, Cleveland JL, et al. Centers for
ejector, is lower than the pressure in saliva ejector; Disease Control and Prevention Guidelines for infection
2. the suction tubing attached to the ejector is posi- control in dental health-care settings–2003. MMWR
tioned above patient’s mouth; or Recomm Rep 2003;52(RR-17):1-61.
3. the saliva ejector is used at same time with other 4. Centers for Disease Control and Prevention. Summary
high-volume suctions. of infection prevention practices in dental settings: Basic
expectations for safe care. 2020. Available at: “https://
Policy statement www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.
The AAPD: pdf ”. Accessed October 5, 2020.
• acknowledges the Centers for Disease Control and Pre- 5. Centers for Disease Control and Prevention. Guidance for
vention’s Guidelines for Infection Control in the Dental Dental Settings. Interim Infection Prevention and Control
Health-Care Setting–20033, Guidelines for Disinfection Guidance for Dental Settings During the Coronavirus
and Sterilization in Healthcare Facilities–2008 18 , Disease 2019 (COVID-19) Pandemic. Accessed October
Updated CDC Recommendations for the Management 5, 2020.
of Hepatitis B Virus-infected Health Care Providers and 6. U.S. Department of Labor Occupational Safety and
Students–201219, and Statement on Reprocessing Dental Health Administration. COVID-19–Control and
Handpieces–2018 20, as in-depth reviews of infection Prevention/Dentistry Workers and Employers. Available
control measures for dental settings and supports the at: “https://www.osha.gov/SLTC/covid-19/dentistry.html”.
strategies therein. Accessed October 5, 2020.
• encourages dental practitioners to follow current literature 7. Hu-Friedy Manufacturing Company LLC. Responses to
and consider carefully infection control measures in their infection control breaches for dental teams. Dent Assist
practices to minimize the risk of disease transmission. 2013;82(4):28-9.
• encourages providers to heat sterilize all dental hand- 8. Mills SE, Porteous N, Zawada J. Dental unit water
pieces, including low-speed motors and reusable quality: Organization for Safety, Asepsis and Prevention
prophylaxis angles, between patients.3 white paper and recommendations–2018. J Dent Infect
• encourages providers and their dental teams to be pro- Control Safety 2018;1(1):1-27.
active in addressing infection control concerns. Staff 9. Hatzenbuehler LA, Tobin-D’Angelo M, Drenzek C, et al.
may benefit from additional training to better answer Pe d i a t r i c d e n t a l c l i n i c - a s s o c i a t e d o u t b re a k o f
questions from parents regarding the infection control Mycobacterium abscessus infection. J Pediatric Infect Dis
practices in their treatment facility. Soc 2017;6(3):e116-e122.
• encourages practitioners to develop a water management 10. Peralta G, Tobin-D’Angelo M, Parham A, et al. Notes
plan that includes routine maintenance procedures for from the Field: Mycobacterium abscessus infections among
dental unit waterlines (according to the manufacturer’s patients of a pediatric dentistry practice – Georgia,
instructions) and monitoring water quality to help keep 2015. MMWR Morb Mortal Wkly 2016;65(13):355-6.
waterline bacterial counts low. Errata in MMWR Morb Mortal Wkly Rep 2016;65
• encourages practitioners to use irrigants for operative and (13):484. Available at: “https://www.cdc.gov/mmwr/
surgical procedures that are consistent with CDC recom- volumes/65/wr/mm6513a5.htm?s_cid=mm6513a5_w”.
mendations. Because conventional dental units cannot Accessed October 5, 2020.
reliably deliver sterile water even when equipped with 11. Ricci ML, Fontana S, Pinci F, et al. Pneumonia associated
independent water reservoirs, a single-use disposable with a dental unit waterline. Lancet 2012;379(9816):
syringe should be used to dispense irrigants for pulpal 684.
therapy and oral surgical procedures. 12. Adler-Shohet FC, Singh J, Nieves D, et al. Safety and
• encourages clinicians to take necessary precautions to tolerability of clofazimine in a cohort of children with
prevent potential backflow associated with use of saliva odontogenic Mycobacterium abscessus infection. J
ejectors. Pediatric Infect Dis Soc 2019:piz049.

13. Moe J, Rajan R, Caltharp S, Abramowicz S. Diagnosis and 18. Rutula WA, Weber DJ, Healthcare Infection Control
management of children with Mycobacterium abscessus Practices Advisory Committee. Guideline for disinfection
infections in the head and neck. J Oral Maxillofac Surg and sterilization in healthcare facilities—2008. Update:
2018;76(9):1902-11. May 2019. Available at: “https://www.cdc.gov/infection
14. Lamb G, Starke J. Mycobacterium abscessus infections in control/pdf/guidelines/disinfection-guidelines-H.pdf ”.
children: A review of current literature. J Pediatric Infect October 5, 2020.
Dis Soc 2018;7(3):e131-144. 19. Centers for Disease Control and Prevention. Updated
15. U.S. Food and Drug Administration. Dental unit water- CDC recommendations for the management of hepatitis
lines. 2018. Available at: “https://www.fda.gov/medical- B virus-infected health-care providers and students.
devices/dental-devices/dental-unit-waterlines”. Accessed MMWR Recomm Rep 2012;61(RR-3):1-12. Erratum in
October 5, 2020. MMWR Recomm Rep 2012;61(28):542.
16. Centers for Disease Control and Prevention. Dental unit 20. Centers for Disease Control and Prevention. CDC State-
water quality. 2016. Available at: “https://www.cdc.gov/ ment on Reprocessing Dental Handpieces. April 11, 2018.
oralhealth/infectioncontrol/faqs/dental-unit-water-quality. Infection Prevention & Control in Dental Settings. Avail-
html”. Accessed October 5, 2020. able at: “https://www.cdc.gov/oralhealth/infectioncontrol/
17. American Dental Association. Dental unit waterlines. statement-on-reprocessing-dental-handpieces.htm”. Accessed
2019. Available at: “https://www.ada.org/en/member- October 5, 2020.
center/oral-health-topics/dental-unit-waterlines”. Accessed
May 13, 2020.

Order The Handbook of Pediatric Dentistry at www.aapd.org today!
CLINICAL PRACTICE GUIDELINES: SILVER DIAMINE FLUORIDE
Recommendations
Clinical Practice Guidelines
CPGs are "statements that
include recommendations
intended to optimize patient
care. They are informed by
a systematic review of
evidence and an assessment
of the benefits and harms
of alternative care options".

Use of Silver Diamine Fluoride for Dental Caries

Management in Children and Adolescents, Including
Those with Special Health Care Needs
Developed by
How to Cite: Crystal YO, Marghalani AA, Ureles SD, et al. Use of silver
diamine fluoride for dental caries management in children and adoles-
cents, including those with special health care needs. Pediatr Dent 2017;
Issued 39(5):E135-E145.
2017
Abstract
Background: This manuscript presents evidence-based guidance on the use of 38 percent silver diamine fluoride (SDF) for dental caries
management in children and adolescents, including those with special health care needs. A guideline workgroup formed by the American
Academy of Pediatric Dentistry developed guidance and an evidence-based recommendation regarding the application of 38 percent SDF
to arrest cavitated caries lesions in primary teeth.
Types of studies reviewed: The basis of the guideline’s recommendation is evidence from an existing systematic review "Clinical trials of
silver diamine fluoride in arresting caries among children: A systematic review." (JDR Clin Transl Res 2016;1[3]:201-10). A systematic search was
conducted in PubMed®/MEDLINE, Embase®, Cochrane Central Register of Controlled Trials, and gray literature databases to identify randomized
controlled trials and systematic reviews reporting on the effect of silver diamine fluoride and address peripheral issues such as adverse effects
and cost. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality
of the evidence and the evidence-to-decision framework was employed to formulate a recommendation.
Results: The panel made a conditional recommendation regarding the use of 38 percent SDF for the arrest of cavitated caries lesions in
primary teeth as part of a comprehensive caries management program. After taking into consideration the low cost of the treatment and the
disease burden of caries, panel members were confident that the benefits of SDF application in the target populations outweigh its possible
undesirable effects. Per GRADE, this is a conditional recommendation based on low-quality evidence.
Conclusions and practical implications: The guideline intends to inform the clinical practices involving the application of 38 percent SDF to
enhance dental caries management outcomes in children and adolescents, including those with special health care needs. These recommended
practices are based upon the best available evidence to-date. A 38 percent SDF protocol is included in Appendix II.
KEYWORDS: SILVER DIAMINE FLUORIDE, CLINICAL RECOMMENDATIONS, GUIDELINE, ANTI-INFECTIVE AGENTS, CARIOSTATIC AGENTS, SILVER COMPOUNDS, CARIES, TOPICAL FLUORIDES
Scope and purpose Agency for Healthcare Research and Quality (AHRQ) of the
The guideline intends to inform the clinical practices involving U.S. Department of Health and Human Services (USDHHS).
the application of silver diamine fluoride (SDF) to enhance Health intents and expected benefits or outcomes. The
dental caries management outcomes in children and adolescents, guideline is based on analysis of data included in a recent system-
including those with special health care needs. Silver diamine atic review and meta-analysis1 and summarizes evidence of the
fluoride in this guideline’s recommendation refers to 38 percent benefits and safety of SDF application in the context of dental
SDF, the only formula available in the United States. These rec- caries management, mainly its effectiveness in arresting cavitated
ommended practices are based upon the best available evidence caries lesions 2 † in the primary dentition. Its intent is to provide
to-date. However, the ultimate decisions regarding disease man- the best available information for practitioners and patients
agement and specific treatment modalities are to be made by or their representatives to determine the risks, benefits, and
the dental professional and the patient or his/her representative, alternatives of SDF application as part of a caries management
acknowledging individuals’ differences in disease propensity,
lifestyle, and environment.
The guideline provides practitioners with easy to understand ABBREVIATIONS
evidence-based recommendations. The American Academy of AAPD: American Academy of Pediatric Dentistry. CCTs: Controlled
Pediatric Dentistry's (AAPD) evidence-based guidelines are being clinical trials. EBDC: Evidence-based dentistry committee. EPA: Envi-
produced in accordance with standards created by the National ronmental Protection Agency. GRADE: Grading of Recommendations
Assessment, Development and Evaluation. NaF: Sodium fluoride. NGC:
Academy of Medicine (formerly known as the Institute of Med-
National Guideline Clearinghouse. PICO: Population, intervention,
icine) and mandated by the National Guideline Clearinghouse™ control, and outcome. RCTs: Randomized control trials. SDF: Silver
(NGC), a database of evidence-based clinical practice guidelines diamine fluoride.
and related documents maintained as a public resource by the

program. Prevention of new caries lesion development and out- Inclusion and exclusion criteria. The criteria used to iden-
comes in permanent teeth, such as root caries lesion arrest, were tify publications for use in the guideline were determined by
not the focus of this guideline; however, because they are of the clinical PICO question. See Appendix I for search strat-
interest and relevant to caries management within the scope egies. Publications which addressed the use of SDF to arrest
of pediatric dentistry, they are mentioned and will be included caries lesions in primary teeth, regardless of language, merited
in future iterations of the guideline as the supporting evidence full-text review; in vitro studies and studies of the use of SDF
base increases. outside of the guideline’s stated outcomes were excluded. No
Clinical questions addressed. The panel members used the new randomized controlled trials were identified that warranted
Population, Intervention, Control, and Outcome (PICO)3 for- updating the meta-analysis found in the systematic review 1
mulation to develop the clinical questions that will aid practi- selected as the basis for this guideline.
tioners in the use of SDF in primary teeth with caries lesions. Assessment of the evidence. The main strength of this
Does the application of SDF arrest cavitated caries lesions as guideline is that it is based on a systematic review of prospective
effectively as other treatment modalities in primary teeth? randomized and controlled trials of SDF1. Evidence was assessed
via the Grading of Recommendations Assessment, Develop-
Methods ment, and Evaluation (GRADE) approach6, a widely adopted
This guideline adheres to the National Academy of Medicine's and peer reviewed system of evaluating study quality (Table 1).
guideline standards4 and the recommendations of the Appraisal The guideline recommendation is based on the meta-analysis of
of Guidelines Research and Evaluation (AGREE) instrument.5 four controlled trials (three randomized), extracted in duplicate,
The guidance presented is based on an evaluation of the evidence from a systematic review of SDF 1. Randomized (RCTs) and
presented in a 2016 systematic review published by Gao and controlled clinical trials (CCTs) offer the highest level of clin-
colleagues.1 ical evidence; therefore, a recommendation based on a systematic
Search strategy. Literature searches were used to identify sys- review and meta-analysis of graded RCTs/CCTs provides more
tematic reviews that would serve as the basis of the guideline. reliable and accurate conclusions that can be applied towards
Secondly, the results of the searches served as sources of evidence patient care.
or information on issues related to, but outside the context of, This guideline is limited by the small number of RCTs
the PICO, such as cost, adverse effects, and patient preferences. evaluating SDF, the heterogeneity of the included trials, and
Literature searches were conducted in PubMed /MEDLINE, ® selection bias that may have been introduced by possibly poor
®
Embase , Cochrane Central Register of Controlled Trials, gray
literature, and trial databases to identify systematic reviews and
sequence generation 7,8 and selective reporting by one study 7.
Weaknesses of this guideline are inherent to the limitations
randomized controlled trials of SDF. Search results were reviewed found in the systematic review 1 upon which this guideline is
in duplicate at both the title and abstract and the full-text level based. Major limitations of the supporting literature include
when warranted. Disagreements were resolved by consensus; lack of calibration and/or evidence of agreement for examiners
if agreement could not be reached, the AAPD Evidence-Based assessing clinical outcomes and unclear definitions or inconsist-
Dentistry Committee (EBDC) overseeing the workgroup was ent criteria for caries lesion activity.9,10 Arguably, without a valid
consulted to settle the question. A detailed description of the and reliable method to determine lesion activity at baseline and
search strategies is presented in Appendix I. follow-up, misclassification bias is possible, especially because
clinicians cannot be blinded with regard to SDF application
(due to the dark staining).9,10 The absence of rigorous caries
† A caries lesion is a detectable change in the tooth structure that results from detection and activity measurement criteria in the reviewed
the biofilm-tooth interactions occurring due to the disease caries. It is the literature can decrease the validity of the reported results.9,10
clinical manifestation (sign) of the caries process.
Table 1. QUALITY OF EVIDENCE GRADES †
Grade Definition
High We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility
that it is substantially different.
Low Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very Low We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
† Quality of evidence is a continuum; any discrete categorization involves some degree of arbitrariness. Nevertheless, advantages of simplicity, transparency, and vividness outweigh
these limitations.
Reprinted with permission. Quality of evidence. GRADE Handbook: Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach.
Update October 2013. Available at: “http://gdt.guidelinedevelopment.org/app/handbook/handbook.html”.

Other reviewers of the systematic review 1 noted similar and Recommendations

additional limitations.9,10 The SDF panel supports the use of 38 percent SDF for the
Formulation of the recommendations. The panel formul- arrest of cavitated caries lesions in primary teeth as part of a
ated this guideline collectively via surveys, teleconferences, and comprehensive caries management program. (Conditional
electronic communications from January 2017–August 2017. recommendation, low-quality evidence)
The panel used the evidence-to-decision framework in an
iterative manner to formulate the recommendations. Specifically, Summary of findings
the main methods used were discussion, debate, and consensus The recommendation is based on data from a meta-analysis of
seeking.11 To reach consensus, the panel voted anonymously on data extracted from RCTs and CCTs of SDF efficacy with va-
all contentious issues and on the final recommendation. GRADE rious follow-up times and controls (Table 3). Based on the
was used to determine the strength of the evidence.12 pooled estimates of SDF group, approximately 68 percent (95
Understanding the recommendations. GRADE rates percent confidence interval [95% CI]=9.7 to 97.7) of cavitated
the strength of a recommendation as either strong or condi- caries lesions in primary teeth would be expected to be arrested
tional. A strong recommendation “is one for which guideline two years after SDF application (with once or twice a year
panel is confident that the desirable effects of an intervention application). Using data with longest follow-up time (at least
outweigh its undesirable effects (strong recommendation for an 30 months follow-up; n=2,567 surfaces from one RCT7 and
intervention) or that the undesirable effects of an intervention one CCT8), SDF had 48 percent higher (95% CI=32 to 66)
outweigh its desirable effects (strong recommendation against an success rate in caries lesion arrest compared to the controls (76
intervention).”6 A strong recommendation implies most patients percent versus 51 percent arrested lesions, in absolute terms).
would benefit from the suggested course of action (i.e., either In other words, 248 more cavitated caries lesions would be ex-
for or against the intervention). A conditional recommendation pected to arrest by treatment with SDF compared to control
“is one for which the desirable effects probably outweigh the treatments, per 1000 surfaces after at least 30 months follow-
undesirable effects (conditional recommendation for an inter- up. Considering the stratum with most data (n=3,313 surfaces
vention) or undesirable effects probably outweigh the desirable from three RCTs and one CCT, with follow-up of 24 months
effects (conditional recommendation against an intervention), but or more), similar estimates of relative and absolute efficacy
appreciable uncertainty exists.”6 A conditional recommendation were produced (i.e., RR 1.42 [95% CI=1.17 to 1.72]) and 72
implies that not all patients would benefit from the intervention. percent versus 50 percent arrested lesions, in absolute terms.
The individual patient’s circumstances, preferences, and values Other follow-up and application frequency strata are listed in the
need to be assessed more than usual. Practitioners need to allo- summary of findings (Table 3). The range of estimates of SDF
cate more time for consultation along with explanation of the efficacy between the included trials was categorically wide.
potential benefits and harms to the patients and their caregivers Rates of arrest on untreated groups may seem unusually high,
when recommendations are rated as conditional. Practitioners’ and this may be due to background fluoride exposure. In one
expertise and judgment as well as patients’ and their caregivers’ of the trials 7, all participants (i.e., both the SDF-treated and
needs and preferences establish the suitability of the recommen- control children) received 0.2 percent sodium fluoride (NaF)
dation to individual patients. The strength of a recommendation rinse every other week in school, while in other trials, children
presents different implications for patients, clinicians, and policy were either given fluoride toothpaste13 or reported use of fluoride
makers (Table 2). toothpaste 8. The panel determined the overall quality of the
Table 2. IMPLICATIONS OF STRONG AND CONDITIONAL RECOMMENDATIONS FOR DIFFERENT USERS OF GUIDELINES
Strong recommendation Conditional recommendation

For patients Most individuals in this situation would want the recommended The majority of individuals in this situation would want the suggested
course of action and only a small proportion would not. course of action, but many would not.
For clinicians Most individuals should receive the recommended course of action. Recognize that different choices will be appropriate for different pa-
Adherence to this recommendation according to the guideline tients, and that you must help each patient arrive at a management
could be used as a quality criterion or performance indicator. Formal decision consistent with her or his values and preferences. Decision
decision aids are not likely to be needed to help individuals make aids may well be useful helping individuals making decisions consistent
decisions consistent with their values and preferences. with their values and preferences. Clinicians should expect to spend
more time with patients when working towards a decision.
For policy The recommendation can be adapted as policy in most situations Policymaking will require substantial debates and involvement of
makers including for the use as performance indicators. many stakeholders. Policies are also more likely to vary between
regions. Performance indicators would have to focus on the fact that
adequate deliberation about the management options has taken place.
Reprinted with permission. GRADE Handbook: Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. Update October 2013.
Available at: “http://gdt.guidelinedevelopment.org/app/handbook/handbook.html”.

evidence for this comparison was low or very low, owing to with special management considerations (e.g., individuals
serious issues of risk of bias (unclear method for randomization, with special health care needs) often requires advanced
selective reporting, and high heterogeneity) in the included pharmacologic behavior guidance modalities (e.g., sedation,
studies. No studies were identified regarding the arresting effect general anesthesia). These pathways of care have additional
of SDF on cavitated caries lesions in adult patients. The panel health risks and limitations (e.g., possible effects on brain
suggests that similar treatment effects may be expected for other development in young children, mortality risks 16), and
age groups, but the lack of evidence informing this recommen- often are not accessible, at all or in a timely manner. 17-19
dation restrained the panel from providing an evidence-based The U.S. Food and Drug Administration has issued a
recommendation. warning “that repeated or lengthy use of general anesthetic
The panel made a conditional recommendation regarding the and sedation drugs during surgeries or procedures in chil-
use of SDF for the arrest of cavitated caries lesions in primary dren younger than three may affect the development of
teeth as part of a comprehensive caries management program. children’s brains.”20
After taking in consideration the low cost of the treatment and 3. The cost of managing severe early childhood caries is
the disease burden of caries, panel members were confident that disproportionally high, especially when hospitalization is
the benefits of SDF application in the target populations out- necessary. The need to treat children in a hospital setting
weigh its possible undesirable effects. Specifically: with general anesthesia is a common scenario in the U.S.
1. Untreated decay in young children remains a challenge, and other countries.21 Studies report that children from the
from clinical and public health standpoints, in the U.S. less-affluent regions have higher dental surgery rates than
and worldwide.14 It confers significant health and quality those from more-affluent communities (25.7 vs. 6.9 per
of life impacts to children and their families, and it is 1,000)17, which results in an economic burden for commu-
marked by pronounced disparities.15 nities already impacted by the effects of poverty-related
2. Surgical-restorative work in young children and those health problems.19,22
Table 3. SUMMARY OF FINDINGS: EVIDENCE FOR THE RELATIVE AND ABSOLUTE EFFICACY OF SDF APPLICATION COMPARED TO NO SDF
FOR THE ARREST OF CAVITATED CARIES LESIONS ON PRIMARY TEETH *
Patient or population: Children and adolescents with cavitated caries lesions on primary teeth
Intervention: SDF (various periodicities)
Comparison: No SDF (various controls, including active agents and treatment)
Outcome: Caries arrest in primary teeth
Follow-up time; Relative Absolute estimates, % arrested lesions Quality

n surfaces (studies) efficacy, RR (95% CI) Ω assessment
(95% CI)
No SDF (other active SDF
controls or no treatment)
24 months; RR 1.45 47.9% 68.0% ȅȅȅȅ

746 surfaces (2 RCTs: Yee et al., 2009 & Zhi et al., 2012) (0.79 to 2.66) (3.8 to 95.6) A (9.7 to 97.7) VERY LOW a,b,c
≥ 24 months; RR 1.42 49.6% 72.4% ȅȅȅȅ

3313 surfaces (3 RCTs: Llodra et al., 2005, Yee et al., 2009 & Zhi et al., (1.17 to 1.72) (28.8 to 70.5)C (48.0 to 88.1) VERY LOW a,d,e
2012., 1 CCT: Chu et al., 2002) n
≥ 30 months; RR 1.48 50.8% 76.4% ȅȅ

ȅȅ
2567 surfaces (1 CCT: Chu et al., 2002 & 1 RCT: Llodra et al., 2005.) U (1.32 to 1.66) (32.5 to 69.0)B (52.1 to 90.6) LOW a,b
semi-annual application RR 1.25 72.4 % 87.7% ȅȅȅȅ

≥ 24 months; (0.99 to 1.58) (47.2 to 88.5) A (80.9 to 92.4) VERY LOW a,d,e
1784 surfaces (2 RCTs: Llodra et al., 2005 & Zhi et al., 2012)
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4. With caries lesion arrest rates upwards of 70 percent (i.e., Guideline implementation. This guideline will be pub-
higher than other comparable interventions), SDF pre- lished in the AAPD’s Reference Manual and the journal, Pediatric
sents as an advantageous modality. Besides its efficacy, Dentistry. Social media, news items, and presentations will be
SDF is favored by its less invasive (clinically and in terms used to notify AAPD members about the new guideline.
of behavior guidance requirements) nature and its inex- This guideline will be available as an open access publication
pensiveness. on the AAPD’s website. Patient education materials are being
5. The undesirable effects of SDF (mainly esthetic concerns developed and will be offered in the AAPD’s online bookstore.
due to dark discoloration of carious SDF-treated dentin) See Appendix II for practical SDF guidance and the Resource
are outweighed by its desirable properties in most cases, Section of the AAPD Reference Manual for a SDF chairside
while no toxicity or adverse events associated with its use guide.26
have been reported. Cost considerations. Silver diamine fluoride is an effective
and inexpensive means of arresting cavitated caries lesions in
In sum, the panel felt confident that a conditional recom- primary teeth. 27 It is inexpensive due to the low cost of ma-
mendation was merited because, although a majority of patients terials and supplies and relatively short chair time required for
would benefit from the intervention, individual circumstances, application. Nevertheless, an empirical cost analysis discussion
preferences, and values need to be assessed by the practitioner for SDF would need to address the several additional considera-
after explanation and consultation with the caregiver. tions and parameters. First, given the wide array of surgical and
Research considerations. Research is needed on the use non-surgical management approaches for cavitated caries lesions
of SDF to arrest caries lesions in both primary and permanent in the primary dentition, agreement on consensus endpoints
teeth. The panel urges researchers to conduct well-designed and, therefore, total cost is challenging and controversial. Second,
randomized clinical trials comparing the outcomes of SDF to cost should include patient/family and practitioner time, health
other treatments for the arrest of caries lesions in primary and care services utilized, and cost of non-health impacts, if any.
permanent teeth. Third, SDF economic analyses are likely best approached via a
Potential adverse effects. Silver diamine fluoride contains cost-utility framework, wherein expenditures are juxtaposed to
approximately 24-28 percent (weight/volume) silver and 5-6 quality-adjusted or disease-free years. To illustrate the import-
percent fluoride (weight/volume).23 Exposure to one drop of SDF ance of defining a consensus treatment endpoint, in this scenario
orally would result in less fluoride ion content than is present disease-free years can be interpreted as caries inactive, no surgical
in a 0.25 milliliters topical treatment of fluoride varnish. The intervention needed, or pain-free years. Finally, the economic
exact amount of silver and fluoride present in one drop of benefits of SDF application must be considered in the context
SDF is determined by the specific gravity of the liquid and the of pathways of clinical care (i.e., disease management) and
dropper used. More studies are required to determine that account, among other factors, for the risks and costs associated
amount, given the stability of the product manufactured and with advanced behavior management techniques (e.g., indicated
packaged in the U.S. surgical-restorative work may require sedation or general anes-
In published clinical trials encompassing over 4,000 young thesia in some cases), families’ preferences, and opportunity costs
children worldwide, exposure to manufacturer’s recommended (e.g., time investment beyond the direct costs).
amounts of SDF has not resulted in any reported deaths or
systemic adverse effects. Recommendation adherence criteria
Oral absorption can include absorption in mucous mem- Guidelines are used by insurers, patients, and health care practi-
branes in the mouth and the nasal cavity. The short-term health tioners to determine quality of care. In principle, following best
effects in humans as a result of exposure to water or food con- practices and guidelines is believed to improve outcomes and
taining specific levels of silver are unknown. The Environmental reduce inappropriate care.28 Therefore, measuring adherence to
Protection Agency (EPA) suggests levels of silver in drinking oral health-related guidelines is key and can serve as manifesta-
water not to exceed 1.142 milligrams per liter (1.142 parts per tion of the dental community’s role as a “responsible steward of
million). Silver diamine fluoride should not be used in patients oral health.”29 Though measurement of oral health outcomes is
with an allergy to silver compounds.24 in its early days at both system and practice levels, system-level
The main disadvantage of SDF is its esthetic result (i.e., performance measures for some oral health areas have been de-
permanently blackens enamel and dentinal caries lesions and veloped by the Dental Quality Alliance of the American Dental
creates a temporary henna-appearing tattoo if allowed to come Association in partnership with the AAPD and other dental
in contact with skin). Skin pigmentation is temporary since organizations. The goals of professional accountability, trans-
the silver does not penetrate the dermis. Desquamation of the parency, and oral health care quality can be furthered through
skin with pigmentation occurs when keratinocytes are shed these measures.
over a period of 14 days.25 Silver diamine fluoride also perma- Workgroup. In December 2016, the AAPD’s Board of
nently stains most surfaces (e.g., counters, clothing) with which Trustees approved a panel nominated by the EBDC to develop
it comes into contact. a new evidence-based clinical practice guideline on SDF. The
panel consisted of general and pediatric dentists in public and

private practice involved in research and education; the stake- Intended users. The target audience for this guideline is
holders consisted of representatives from general dentistry, dental general dentists, pediatric dentists, pediatricians, and family
hygiene, governmental and non-governmental agencies, and practice physicians. Public and private payors will benefit from
international and specialty dental organizations. reviewing the evidence for coverage decisions regarding SDF
Stakeholders and external review. This guideline was re- use, and patients and patient advocates may find it useful as a
viewed by external and internal stakeholders continuously from reference for current available treatments for caries management.
the beginning of the process until the formulation of the guide- The target populations include children and adolescents, in-
line. Stakeholders were invited to take part in anonymous surveys cluding those with special health care needs.
to determine the scope and outcomes of the guideline, bringing Guideline updating process. The AAPD’s EBDC will
in points of view from different geographical regions, dental monitor the biomedical literature to identify new evidence that
specialties, and patient advocates. Comments also were sought may impact the current recommendations. These recommen-
on the draft of the guideline. All stakeholder comments were dations will be updated five years from the time the last
taken into consideration, addressed, and acted upon as appro- systematic search, unless the EBDC determines that an earlier
priate per group deliberation. Additional feedback from revision or update is warranted.
stakeholders is expected after publication and dissemination of
the guideline. References appear after Appendices.
Appendices
Appendix I—Search strategies Search #4. 410530 results
(systematic[sb] OR meta-analysis[pt] OR meta-analysis as
®
PubMed (MEDLINE)– no date limit
topic[mh] OR meta-analysis[mh] OR meta analy*[tw] OR
Search #1. 145 results metanaly*[tw] OR metaanaly*[tw] OR met analy*[tw] OR research
cariestop OR "silver diamine fluoride"[Supplementary Concept] overview*[tiab] OR collaborative review*[tiab] OR col-
OR "silver diamine" OR "silver diammine" OR “diamine fluor- laborative overview*[tiab] OR systematic review*[tiab] OR
ide” OR “diammine fluoride” OR saforide OR “Riva star” comparative efficacy[tiab] OR comparative effectiveness[tiab]
OR outcomes research[tiab] OR systematic overview*[tiab] OR
Search #2. 6589771 results methodological overview*[tiab] OR methodologic overview*
(randomized controlled trial[pt] OR controlled clinical trial [tiab] OR methodological review*[tiab] OR methodologic
[pt] OR randomi*[tiab] OR randomization[tiab] OR random- review*[tiab] OR quantitative review*[tiab] OR quantitative
isation[tiab] OR placebo[tiab] OR drug therapy[sh] OR overview*[tiab] OR quantitative synthes*[tiab] OR pooled
randomly[tiab] OR trial[tiab] OR groups[tiab] OR Clinical analy*[tiab] OR Cochrane[tiab] OR Medline[tiab] OR Pubmed
trial[pt] OR "clinical trial"[tw] OR "clinical trials"[tw] OR [tiab] OR Medlars[tiab] OR handsearch*[tiab] OR hand search*
"evaluation studies"[Publication Type] OR "evaluation studies [tiab] OR meta-regression*[tiab] OR metaregression*[tiab]
as topic"[MeSH Terms] OR "evaluation study"[tw] OR evalu- OR data synthes*[tiab] OR data extraction[tiab] OR data
ation studies[tw] OR "intervention studies"[MeSH Terms] OR abstraction*[tiab] OR mantel haenszel[tiab] OR peto[tiab] OR
"intervention study"[tw] OR "intervention studies"[tw] OR dersimonian[tiab] OR dersimonian[tiab] OR fixed effect*
"cohort studies"[MeSH Terms] OR cohort[tw] OR "longitu- [tiab] OR "Cochrane Database Syst Rev"[Journal])
dinal studies"[MeSH Terms] OR "longitudinal"[tw] OR
longitudinally[tw] OR "prospective"[tw] OR prospectively[tw] Search #5. 14 results
OR "follow up"[tw] OR "comparative study"[Publication #1 and #4*
Type] OR "comparative study"[tw] OR systematic[subset] OR
"meta-analysis"[Publication Type] OR "meta-analysis as topic" Search #6. 890576 results
[MeSH Terms] OR "meta-analysis"[tw] OR "meta-analyses" ("Economics"[Mesh] OR "Cost of Illness"[Mesh] OR "Cost
[tw]) NOT (animals [mh] NOT humans [mh]) Savings"[Mesh] OR "Cost Control"[Mesh] OR "Cost-Benefit
Analysis"[Mesh] OR "Health Care Costs"[Mesh] OR "Direct
Search #3. 14 results Service Costs"[Mesh] OR "economics"[Subheading] OR cost))
#1 and #2
Search #7. 8 results
#1 AND #6
* Search results vetted in duplicate using an evidence-based minimum set of

items for reporting in systematic reviews and meta-analyses checklist.

Appendix II—Practical guidance * esthetic purposes.30 Functional indicator of effectiveness (i.e.,

caries arrest) is when staining on dentinal carious surfaces is
* Silver diamine fluoride in this guideline’s recommendation visible.
refers to 38 percent SDF, the only formula available in
the United States. The following steps may vary depending on differing prac-
tices, settings, and patients:
Setting • Remove gross debris from cavitation to allow better SDF
Practitioners must first consider the current standard of care of contact with denatured dentin.
the setting where SDF therapy is intended for use. Silver dia- • Minimize contact with gingiva and mucous membranes to
mine fluoride is optimally utilized in the context of a chronic avoid potential pigmentation or irritation; consider apply-
disease management protocol, one that allows for the moni- ing cocoa butter or use cotton rolls to protect surrounding
toring of the clinical effectiveness of SDF treatment, disease gingival tissues, with care to not inadvertently coat the
control, and risk assessment. surfaces of the carious lesion.
Practical recommendation: Know the setting where SDF is • Dry with a gentle flow of compressed air (or use cotton
to be used to be consistent with goals of patient-centered care. rolls/gauze to dry) affected tooth surfaces.
• Bend micro sponge brush, dip and dab on the side of the
Indications and usage dappen dish to remove excess liquid before application;24
The following scenarios may be well-suited for the use SDF: apply SDF directly to only the affected tooth surface.
• High caries-risk patients with anterior or posterior active • Dry with a gentle flow of compressed air for at least one
cavitated lesions. minute.
• Cavitated caries lesions in individuals presenting with be- • Remove excess SDF with gauze, cotton roll, or cotton pellet
havioral or medical management challenges. to minimize systemic absorption.4 Continue to isolate site
• Patients with multiple cavitated caries lesions that may not for up to three minutes when possible.
all be treated in one visit.
• Difficult to treat cavitated dental caries lesions. Practical recommendation: No need for surgical intervention
• Patients without access to or with difficulty accessing dental (e.g., dentin excavation). SDF application is minimally invasive
care. and easy for the patient and the practitioner. It may be desirable
• Active cavitated caries lesions with no clinical signs of pulp for the caries lesion to be free of gross debris for SDF to have
involvement. maximum contact with the affected dentin surface.
Practical recommendation: SDF is a valuable caries lesion– Application time

arresting tool that can be used in the context of caries man- An application time of one minute, drying with a gentle flow
agement. Evaluate carefully which patients/teeth will benefit of compressed air, is recommended. Clinical studies that report
from SDF application. application times range from 10 seconds to three minutes. A
current review states that application time in clinical studies
Preparation of patients and practitioners does not correlate to outcome. 24 More studies are needed to
Informed consent, particularly highlighting expected staining confirm an ideal protocol.
of treated lesions, potential staining of skin and clothes, and need Practical recommendation: Ideal time of application should
for reapplication for disease control, is recommended. be one minute, using a gentle flow of compressed air until
The following practices are presented to support patient safety liquid is dry. When using shorter application periods, monitor
and effectively use SDF: carefully at post-op and re-care to evaluate arrest and consider
• Universal precautions. re-application.
• No operative intervention (e.g., affected or infected dentin
removal) is necessary to achieve caries arrest.8 Post-operative instructions
• Protect patient with plastic-lined bib and glasses. No postoperative limitations are listed by the manufacturer.
• Cotton roll or other isolation as appropriate. Eating and drinking immediately following application is
• Use a plastic dappen dish as SDF corrodes glass and metal. acceptable. Patients may brush with fluoridated toothpaste as
• Carefully dispose of gloves, cotton rolls, and micro brush per regular routine following SDF application.
into plastic waste bag. Several SDF clinical trials recommended no eating or drink-
ing for 30 minutes – one hour. 13,31,32 As patients are used to
Application these recommendations for in-office topical fluoride applications,
Carious dentin excavation prior to SDF application is not neces- the recommendation may not be unreasonable to patients, and
sary.8 Caries dentin excavation may reduce proportion of arrested it may allow for better arrest results. More clinical studies are
caries lesions that become black, and may be considered for needed to establish best practices.

Application frequency Adverse reactions

The effectiveness of one-time SDF application in arresting dental No severe pulpal damage or reaction to SDF has been re-
caries lesions ranges from 47 percent to 90 percent, depending ported.7,36-38 However, SDF should not be placed on exposed
on the lesion size and the location of the tooth and the lesion. pulps. Teeth with deep caries lesions should be closely monitored
One study showed that anterior teeth had higher rates of clinically and radiographically.
caries lesion arrest than posterior teeth.33 The effectiveness of Serum concentration of fluoride following SDF application
caries lesion arrest, however, decreases over time. After a single per manufacturer recommendations posed little toxicity risk
application of 38 percent SDF, 50 percent of the arrested sur- and was below EPA oral reference dose in adults.39
faces at six months had reverted to active lesions at 24 months.13 The following adverse effects have been noted in the literature:
Reapplication may be necessary to sustain arrest.8,31-33 Annual • Metallic/bitter taste.24
application of SDF is more effective in arresting caries lesions • Temporary staining to skin which resolves in 2-14 days.24
than application of five percent sodium fluoride varnish four • Mucosal irritation/lesions resulting from inadvertent con-
times per year.30 Increasing frequency of application can increase tact with SDF, resolved within 48 hours.7
caries arrest rate. Biannual application of SDF increased the rate
of caries lesion arrest compared to annual application.33 Studies Esthetics
that had three times per year applications showed higher arrest The hallmark of SDF is a visible dark staining that is a sign of
rates.7,31,33,34 Frequency of application after baseline has been caries arrest on treated dentin lesions. This dark discoloration
suggested at three month follow up, and then semiannual recall is permanent unless restored. A recent study that assessed pa-
visits over two years. 24 One option is to place SDF on active rental perceptions and acceptance of SDF based on the staining
lesions in conjunction with fluoride varnish (FV) on the rest of found that staining on posterior teeth was more acceptable than
the dentition, or alternate SDF on caries lesions and FV on the on anterior teeth. 40 Although staining on anterior teeth was
rest of the dentition at three months interval to achieve arrest perceived as undesirable, most parents preferred this option to
and prevention in high risk individuals.35 Another study recom- avoid the use of advanced behavioral guidance techniques such
mends one month post operative evaluation of treated lesions as sedation or general anesthesia to deliver traditional restorative
with optional reapplication as required to achieve arrest of all care. It was also found that about one-third of parents found
targeted lesions.35 Individuals with high plaque index and lesions SDF treatment unacceptable under any circumstance due to
with plaque present display lower rates of arrest. Addressing esthetic concerns. To identify those patients, a thorough in-
other risk factors like presence of plaque may increase the rate of formed consent, preferably with photographs that show typical
successful treatment outcomes.33 staining, is imperative.40 To improve esthetics, once the disease
Practical recommendation: If the setting allows, monitor caries is controlled and patient’s circumstances allow, treated and
lesion arrest after 2-4 week period and consider reapplication now-arrested cavitated caries lesions can be restored.35
as necessary to achieve arrest of all targeted lesions. Provide
re-care monitoring based on patient’s disease activity and Other considerations
caries risk level (every three, four, or six months). Careful • Coding – D1354; Reimbursement for this procedure varies
monitoring and behavioral intervention to reduce individual among states and carriers. Third-party payors’ coverage is
risk factors should be part of a comprehensive caries manage- not consistent on the use of this code per tooth or per visit.
ment program that aims not only to sustain arrest of existing Practitioners are cautioned to check insurance coverage for
caries lesions, but also to prevent new caries lesion development. this code as it is transitioning in most areas.
• Caries arrest is more likely on the maxillary anterior teeth8,31
and buccal/lingual smooth surfaces31.
• Pretreatment of dentin with SDF does not adversely affect
bond strength of resin composite to dentin.41,42
References on the next page.

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143-52.

CLINICAL PRACTICE GUIDELINES: PIT AND FISSURE SEALANTS
Use of Pit-and-Fissure Sealants

Developed by How to Cite: Wright JT, Crall JJ, Fontana M, et al. Evidence-based clinical
American Academy of Pediatric Dentistry and American Dental Association practice guideline for the use of pit-and-fissure sealants. American
Academy of Pediatric Dentistry, American Dental Association. Pediatr
Issued
2016 Dent 2016;38(5):E120-E36.
Abstract
Background: This article presents evidence-based clinical recommendations for the use of pit-and-fissure sealants on the occlusal surfaces of
primary and permanent molars in children and adolescents. A guideline panel convened by the American Dental Association (ADA) Council on
Scientific Affairs and the American Academy of Pediatric Dentistry conducted a systematic review and formulated recommendations to address
clinical questions in relation to the efficacy, retention, and potential side effects of sealants to prevent dental caries; their efficacy compared
with fluoride varnishes; and a head-to-head comparison of the different types of sealant material used to prevent caries on pits-and-fissures of
occlusal surfaces.
Types of studies reviewed: This is an update of the ADA 2008 recommendations on the use of pit-and-fissure sealants on the occlusal sur-
faces of primary and permanent molars. The authors conducted a systematic search in MEDLINE, Embase, Cochrane Central Register of Controlled
Trials, and other sources to identify randomized controlled trials reporting on the effect of sealants (available on the U.S. market) when applied
to the occlusal surfaces of primary and permanent molars. The authors used the Grading of Recommendations Assessment, Development, and
Evaluation approach to assess the quality of the evidence and to move from the evidence to the decisions.
Results: The guideline panel formulated 3 main recommendations. They concluded that sealants are effective in preventing and arresting pit-
and-fissure occlusal carious lesions of primary and permanent molars in children and adolescents compared with the nonuse of sealants
or use of fluoride varnishes. They also concluded that sealants could minimize the progression of non-cavitated occlusal carious lesions (also
referred to as initial lesions) that receive a sealant. Finally, based on the available limited evidence, the panel was unable to provide specific recom-
mendations on the relative merits of 1 type of sealant material over the others.
Conclusions and practical implications: These recommendations are designed to inform practitioners during the clinical decision-making
process in relation to the prevention of occlusal carious lesions in children and adolescents. Clinicians are encouraged to discuss the inform-
ation in this guideline with patients or the parents of patients. The authors recommend that clinicians re-orient their efforts toward increasing
the use of sealants on the occlusal surfaces of primary and permanent molars in children and adolescents.
KEYWORDS: PIT-AND-FISSURE SEALANTS, CLINICAL RECOMMENDATIONS, GUIDELINE, OCCLUSAL CARIES, CARIES PREVENTION, CARIES ARRESTING
Pit-and-fissure sealants have been used for nearly 5 decades to regarding when and how the placement of pit-and-fissure
prevent and control carious lesions on primary and permanent sealants is most likely to be effective in preventing carious lesions
teeth. Sealants are still underused despite their documented effi- on the occlusal surfaces of primary and permanent teeth in
cacy and the availability of clinical practice guidelines. 1,2 New children and adolescents. The target audience for this guideline
sealant materials and techniques continue to emerge for man- includes general and pediatric dental practitioners and their
aging pit-and-fissure caries, further complicating the clinician’s support teams, public health dentists, dental hygienists, pediatri-
decision making. Accordingly, continuous critical review of the cians, primary-care physicians, and community dental health
available evidence is necessary to update evidence-based recom- coordinators; policy makers may also benefit from this guideline
mendations and assist health care providers in clinical decision to inform clinical decision making, programmatic decisions,
making.1,7 and public health policy.
The American Dental Association (ADA) Council on
Scientific Affairs convened an expert panel to develop the pre- Definition of dental caries
vious evidence-based clinical recommendations for the use of Dental caries is a disease caused by an ecological shift in the
sealants, published in 2008. 3 In an effort to update the 2008 composition and activity of the bacterial biofilm when exposed
recommendations, the ADA Council on Scientific Affairs and over time to fermentable carbohydrates, leading to a break in
the ADA Center for Evidence-Based Dentistry, in collaboration
with the American Academy of Pediatric Dentistry (AAPD),
convened a new working group including clinical experts, ABBREVIATIONS
stakeholders, and methodologists to develop a systematic review8 AAPD: American Academy of Pediatric Dentistry. ADA: American Den-
tal Association. BPA: Bisphenol A. CIs: Confidence intervals. GI: Glass
and accompanying evidence-based clinical practice recommenda- ionomer. GRADE: Grading of Recommendations Assessment, Devel-
tions for publication in 2016. opment and Evaluation. NHANES: National Health and Nutrition
Our goal for this 2016 clinical practice guideline was to Examination Survey. OR: Odds ratio.
provide clinicians with updated evidence-based recommendations

the balance between demineralization and remineralization. 4 debris and promote the presence of bacterial biofilm, thereby
Carious lesions are preventable by averting onset, and manage- increasing the risk of developing carious lesions. Effectively
able by implementing interventions, which may halt progression penetrating and sealing these surfaces with a dental material—
from early stage of the disease to cavitation, characterized by for example, pit-and-fissure sealants—can prevent lesions and
enamel demineralization, to frank cavitation.3 In 2015, the ADA is part of a comprehensive caries management approach.11
published the Caries Classification System, which defines a non- From a secondary prevention perspective, there is evidence
cavitated or initial lesion as “initial caries lesion development, that sealants also can inhibit the progression of noncavitated
before cavitation occurs. Noncavitated lesions are characterized carious lesions. 9 The use of sealants to arrest or inhibit the
by a change in color, glossiness, or surface structure as a result progression of carious lesions is important to the clinician
of demineralization before there is macroscopic breakdown in when determining the appropriate intervention for noncavitated
surface tooth structure.”4 carious lesions.
Epidemiology Sealant materials and placement techniques

National Health and Nutrition Examination Survey (NHANES) For the purposes of this report, there are 4 sealant materials
2011-20125 data show that 21% of children aged 6 to 11 years under a classification proposed by Anusavice and colleagues11:
and 58% of adolescents aged 12 to 19 years had experienced resin-based sealants, glass ionomer (GI) cements, GI sealants,
carious lesions (untreated and treated [restored]) in their perma- polyacid-modified resin sealants, and resin-modified GI sealants.
nent teeth. They defined the materials as follows.11
The NHANES report also found the prevalence of carious • Resin-based sealants are urethane dimethacrylate, “UDMA,”
lesions in permanent teeth increased with age and differed among or bisphenol A-glycidyl methacrylate (also known as
sociodemographic groups. Children in the 9- to 11-year range “bis-GMA”) monomers polymerized by either a chemical
had higher carious lesion prevalence (29%) compared with chil- activator and initiator or light of a specific wavelength and
dren in the 6- to 8-year range (14%). Similarly, children in the intensity. Resin-based sealants come as unfilled, colorless,
16- to 19-year age range had higher carious lesion prevalence or tinted transparent materials or as filled, opaque, tooth-
(67%) compared with children in the 12- to 15-year range colored, or white materials.
(50%). In addition, dental caries incidence for both 6- to 11- • GI sealants are cements that were developed and are used
year and 12- to 19-year age groups was highest among Hispanic for their fluoride-release properties, stemming from the acid-
children compared with non-Hispanic black children, non- base reaction between a fluoroaluminosilicate glass powder
Hispanic white children, and Asian children. The surgeon and an aqueous-based polyacrylic acid solution.
general’s report on oral health similarly indicated that Hispanic • Polyacid-modified resin sealants, also referred to as compo-
and non-Hispanic black children are at the highest risk of mers, combine resin-based material found in traditional
developing dental caries. 6 Overall, NHANES 2011-2012 resin-based sealants with the fluoride-releasing and adhesive
indicates a higher prevalence of untreated carious lesions in properties of GI sealants.
the 12- to 19-year age group (15%) compared with the 6- to • Resin-modified GI sealants are essentially GI sealants with
11-year age group (6%).5 resin components. This type of sealant has similar fluoride-
Although there has been a decline in prevalence of caries release properties as GI, but it has a longer working time
in adolescents and children in particular, the decrease in occlusal and less water sensitivity than do traditional GI sealants.
surface caries has not kept pace with the decrease in the smooth Placement techniques for pit-and-fissure sealants vary based
surface caries.7 Although this overall decline has been attributed on sealant type and the manufacturer or brand.3 Manufacturers’
to preventive interventions such as water fluoridation, fluoride instructions usually detail cleaning and isolation of the occlusal
tooth-paste, fluoride varnishes, and sealants, topical fluoride surface and encourage a dry environment during sealant place-
applications—such as fluoride varnishes—may have a greater ment and curing. Acid etching of occlusal surfaces is required
effect reducing carious lesions on smooth surfaces compared before resin-based sealant placement. Other techniques men-
with caries in pits and fissures.1-7,9,10 tioned in the studies included in the 2008 report are the use of
NHANES 2011-2012 data show that 41% of children aged bonding agents or adhesives, as well as mechanical preparations
9 to 11 years and 43% of adolescents aged 12 to 19 years had at such as air abrasion or enameloplasty.3
least 1 dental sealant. Non-Hispanic black children had the
lowest dental sealant prevalence in both age groups compared Clinical questions regarding pit-and-fissures sealants
with Hispanic, non-Hispanic white, and Asian children.5 There- To assist clinicians in the use of pit-and-fissure sealants in
fore, underutilization of sealants is of key concern. occlusal surfaces of primary and permanent molars, the guide-
line panel developed the following clinical questions:
Potential role of pit-and-fissure sealants in primary and • Should dental sealants, when compared with nonuse of
secondary prevention sealants, be used in pits and fissures of occlusal surfaces of
From a primary prevention perspective, anatomic grooves or pits primary and permanent molars on teeth deemed to have clin-
and fissures on occlusal surfaces of permanent molars trap food ically sound occlusal surfaces or noncavitated carious lesions?

• Should dental sealants, when compared with fluoride var- certainty in the evidence as high, moderate, low, or very low
nishes, be used in pits and fissures of occlusal surfaces of pri- (Table 113-15), depending on whether the body of evidence
mary and permanent molars on teeth deemed to have clin- at an outcome level includes serious or very serious issues as
ically sound occlusal surfaces or noncavitated carious lesions? follows:
• Which type of sealant material should be used in pits and • Risk of bias: When the studies that are part of the body of
fissures of occlusal surfaces of primary and permanent mo- evidence are affected by serious or very serious limitations in
lars on teeth deemed to have clinically sound occlusal sur- study design, the confidence in the estimates of effect is re-
faces or noncavitated carious lesions? duced owing to the increased risk of bias.16
• Are there any adverse events associated with the use of pit- • Imprecision: When the confidence intervals (CIs) of the data
and-fissure sealants? used for the treatment effects are too wide to make decisions,
the confidence in the estimates of effect is reduced owing to
Methods issues of imprecision. Typically, imprecision occurs when the
This clinical practice guideline follows the recommendations of CIs suggest both a large benefit on one side and a large harm
the Appraisal of Guidelines Research & Evaluation (known as on the other side.17
“AGREE”) reporting checklist.10 • Inconsistency: When the studies comprising the body of evi-
Guideline panel configuration. The ADA Council on dence provide inconsistent results, the confidence in the
Scientific Affairs and the AAPD convened a guideline panel in estimates of effect is reduced owing to the unexplained hetero-
2014. The members of this panel were recognized for their geneity among them.18
level of clinical and research expertise and represented the differ- • Indirectness: When the population, interventions, comparator,
ent perspectives required for clinical decision making (general or outcomes reported in the studies comprising the body of
dentists, pediatric dentists, dental hygienists, and health policy evidence do not directly match the ones the panel requires to
makers). Methodologists from the ADA Center for Evidence- make an informed decision, the confidence in the estimates
Based Dentistry oversaw the guideline development process. of effect is reduced owing to this mismatching issue.19
Scope and purpose. The purpose of these recommendations • Publication bias: When there is suspicion that not all studies
is to provide guidance on sealant use for the prevention of pit- conducted to inform a particular treatment effect are avail-
and-fissure occlusal carious lesions in both primary and per- able or they were selectively published or unpublished, the
manent molars. The target audience for this guideline are confidence in the estimates of effect is reduced owing to the
front-line clinicians in general practice, pediatric dentists, dental suspicion of reporting bias.20
hygienists, dental therapists, community dental health coordina-
tors, dental health policy makers and program planners, and Moving from the evidence to the decisions. To assist the
other members of the dental team. Although the evidence came guideline panel with formulating recommendations and grading
from various settings, we excluded those sealant materials not the strength of the recommendations, we used the evidence-to-
commercially available at the time of this review. decision framework, including the following domains: balance
Retrieving the evidence. Our systematic review methodol- between the desirable and undesirable consequences (net effect),
ogy for developing this guideline is presented elsewhere. 8 certainty in the evidence (also called quality of the evidence),
Briefly, we conducted systematic searches in MEDLINE, patients’ values and preferences, and resource use.14,15 According
Embase, Cochrane Central Register of Controlled Trials, and to the GRADE approach, the strength of a recommendation is
other sources to identify randomized controlled trials reporting either strong or conditional, in which each grade of the strength
on the effect of sealants (available on the U.S. market) when has different implications for patients, clinicians, and policy
applied to the occlusal surfaces of primary and permanent makers (Table 1).
molars. After pairs of independent reviewers conducted title The guideline recommendations in this article were formu-
and abstract retrieval, full-text screening, and data extraction, lated collectively via 3 videoconferences with members of the
we organized the data retrieved using Grading of Recommenda- guideline panel and methodologists from the ADA Center for
tions Assessment, Development, and Evaluation (GRADE) evi- Evidence-Based Dentistry and the AAPD held in January 2016.
dence profiles. In addition, we requested the guideline panel to Deliberation and consensus were the main methods to develop
rank the relative importance of outcomes for decision making these recommendations using the “evidence-to-decision” frame-
in 3 categories (critical, important, and not important) following work.14,15 When consensus was elusive, the panel was presented
guidance from the GRADE working group.12 with the positions under assessment, and it voted accordingly.21
Assessing the certainty in the evidence. We assessed the We identified potential conflicts of interest and managed them
certainty in the evidence (also known as the quality of the evi- according to the recommendations from the World Health
dence) using the approach described by the GRADE working Organization and other guideline development agencies.22
group.13 The certainty in the evidence in the context of clinical Guideline updating process. The ADA Center for Evidence-
practice guidelines reflects the extent to which the guideline Based Dentistry and the AAPD monitor the literature to iden-
panel felt confident about the estimates of effect used for the tify new studies that may be included in the recommendations.
decision-making process. The GRADE approach classifies the These recommendations will be updated 5 years from the date

of submission for publication or when new evidence dictates that and harms, low- to very low-quality evidence, important
the panel change the course of action suggested in this guideline. variability in patients’ values and preferences, and substantial
costs or challenges when trying to implement the intervention
Recommendations (Table 1). 4,14,15 When facing a conditional recommendation,
How to use these recommendations. The recommendations in clinicians should pay special attention to the reasons that justify
this clinical practice guideline aim to assist patients, clinicians, such judgment from the guideline panel. This information can
and other stakeholders when making health care decisions. Al- be found in the remarks section presented with each recommend-
though this clinical practice guideline covers the typical patient ation. Table 2 shows a summary of the key recommendations
that the target audience treats on a daily basis, there may be included in this guideline.
specific situations in which clinicians may want to deviate from
the recommendations listed below. Clinical expertise plays a Question 1. Should dental sealants, when compared with
key role in determining which patients fit into the scope of this non-use of sealants, be used in pits and fissures of occlusal
guideline and how these recommendations align with the values, surfaces of primary and permanent molars on teeth deemed
preferences, and the context of an individual patient.23 to have clinically sound occlusal surfaces or noncavitated
When the panel grades a recommendation as strong, this carious lesions?
means that in most situations clinicians may want to follow the Summary of findings. Data from 9 randomized controlled trials9,
24-31
course of action suggested by the panel and only in a selected showed that in children and adolescents with sound occlu-
few circumstances may they need to deviate from it. Strong rec- sal surfaces, the use of pit-and-fissure sealants compared with
ommendations are usually associated with benefits or harms nonuse of sealants, reduces the incidence of occlusal carious
clearly outweighing one over the other, based on high- to lesions in permanent molars by 76% after 2 to 3 years of
moderate-quality evidence (certainty in the evidence), overall follow-up (odds ratio [OR], 0.24; 95% CI, 0.19-0.30)
homogeneous values and preferences among patients, and in- (sTable 1, available in the supplemental data following refer-
expensive or easy-to-implement interventions.14,15 Conditional ences). In absolute terms, for a population with a caries baseline
recommendations, on the other hand, indicate that clinicians risk (prevalence) of 30%, 207 carious lesions would be prevented
may want to follow the course of action suggested by the panel; out of 1,000 sealant applications (95% CI, 186-225 fewer
however, the panel also recognizes that different choices would lesions) after 2 to 3 years of follow-up. Available data assessing
be appropriate for individual patients. This type of recommenda- the effect of sealants compared with a control without sealants in
tion is usually associated with a close balance between benefits a mixed population of patients with sound occlusal surfaces and
Table 1. DEFINITION OF QUALITY OF THE EVIDENCE AND STRENGTH OF RECOMMENDATIONS
EVIDENCE QUALITY AND CERTAINTY DEFINITIONS *
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DEFINITION OF STRONG AND CONDITIONAL RECOMMENDATIONS AND IMPLICATIONS FOR STAKEHOLDERS†
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† Sources: Andrews and colleagues.14,15

Table 2. SUMMARY OF CLINICAL RECOMMENDATIONS ON THE USE OF PIT-AND-FISSURE SEALANTS IN THE OCCLUSAL SURFACES OF
PRIMARY AND PERMANENT MOLARS IN CHILDREN AND ADOLESCENTS
QUESTION RECOMMENDATION QUALITY OF STRENGTH OF
THE EVIDENCE RECOMMENDATION
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* These recommendations are applicable to both sound surfaces and noncavitated carious lesions: “Noncavitated lesions are characterized by a change in
color, glossiness, or surface structure as a result of demineralization before there is macroscopic breakdown in surface tooth structure. These lesions represent
areas with net mineral loss due to an imbalance between demineralization and remineralization. Reestablishing a balance between demineralization and
remineralization may stop the caries disease process while leaving a visible clinical sign of past disease.”4
† The guideline panel suggests that clinicians should take into account the likelihood of experiencing lack of retention when choosing the type of sealant
material most appropriate for a specific patient and clinical scenario. For example, in situations in which dry isolation is difficult, such as a tooth that is
not fully erupted and has soft tissue impinging on the area to be sealed, then a material that is more hydrophilic (for example, glass ionomer) would be
preferable to a hydrophobic resin-based sealant. On the other hand, if the tooth can be isolated to ensure a dry site and long-term retention is desired, then
a resin-based sealant may be preferable.
noncavitated occlusal carious lesions showed that sealants re- • This recommendation is intended to inform clinicians about
duced the incidence of carious lesions in this population by 75% the benefit of sealing a tooth compared with not sealing it,
(OR, 0.25; 95% CI, 0.19-0.34) after 2 to 3 years of follow-up. irrespective of the type of sealant material applied.
The guideline panel determined the overall quality of the evi- • The panel highlighted that a number of studies have shown
dence for this comparison as moderate owing to serious issues of that sealing children’s and adolescents’ permanent molars
risk of bias (unclear method for randomization and allocation reduces costs to the health system by delaying and preventing
concealment) in the included studies. No data on the effect of the need for invasive restorative treatment, particularly when
sealants in adult patients were identified. these patients are classified as having an “elevated caries risk”
Recommendation. The sealant guideline panel recommends (that is, previous caries experience).32 Under these conditions,
the use of sealants compared with nonuse in primary and perma- dental sealants seem to be a cost-effective intervention.33-36
nent molars with both sound occlusal surfaces and noncavitated • In addition to the evidence collected by the panel from ran-
occlusal carious lesions in children and adolescents. (Strong rec- domized controlled trials suggesting a beneficial effect of
ommendation, moderate-quality evidence.) sealants in noncavitated occlusal carious lesions, the body of
Remarks. evidence from observational studies shows similar results.37,38
• No studies were identified regarding the effect of sealants
on preventing and arresting occlusal carious lesions in adult Research priorities.
patients. For clinicians and patients attempting to extend • Although the analysis was stratified using 2 caries baseline
this recommendation to adults, the guideline panel suggests risks (30% caries prevalence in the article and 70% caries
that similar treatment effects may be expected for other age prevalence in the tables), the guideline panel acknowledged
groups, particularly in adults with a recent history of dental that clinicians lack a valid and reliable tool to conduct a
caries. The lack of direct evidence informing this recommen- chair-side caries risk assessment, especially when it comes to
dation restrained the guideline panel from formulating a assessing a specific tooth surface or site. There is a need for
more definitive recommendation in this regard. such a tool to enable clinicians to perform a more accurate

assessment of the patient’s caries risk and to enable the panel Comparison 3.1. GI sealants compared with resin-based
to provide more specific recommendations using an accurate sealants.
patient caries risk estimation. Summary of findings. Data from 10 randomized controlled
• The panel highlighted the need for additional studies assess- trials40-49 included in the meta-analysis suggest that in children
ing the effect of sealants in the primary dentition. and adolescents with sound occlusal surfaces, the use of GI seal-
ants compared with resin-based sealants may reduce the inci-
Question 2. Should dental sealants, when compared with dence of occlusal carious lesions in permanent molars by 37%
fluoride varnishes, be used in pits and fissures of occlusal after 2 to 3 years of follow-up (OR, 0.71; 95% CI, 0.32-1.57);
surfaces of primary and permanent molars on teeth deemed however, this difference was not statistically significant (P=.39)
to have clinically sound occlusal surfaces or noncavitated (sTable 3, available in the supplemental data following refer-
carious lesions? ences). In absolute terms, for a population with a caries baseline
Summary of findings. Data from 3 randomized controlled risk (prevalence) of 30%, this means that use of a GI sealant
trials25,27,39 suggest that in children and adolescents with sound would prevent 67 carious lesions out of 1,000 sealant applications
occlusal surfaces, the use of pit-and-fissure sealants compared (95% CI, 102 more -179 fewer lesions) compared with using a
with fluoride varnishes may reduce the incidence of occlusal resin-based sealant after 2 to 3 years of follow-up; however, this
carious lesions in permanent molars by 73% after 2 to 3 years difference was not statistically significant. One additional study
of follow-up (OR, 0.27; 95% CI, 0.11-0.69) (sTable 2, available with 200 participants that we were unable to include in the meta-
in the supplemental data following references). In absolute terms, analysis owing to the data presentation failed to show a clinically
for a population with a caries baseline risk (prevalence) of 30%, or statistically significant difference in caries incidence when GI
196 carious lesions would be prevented out of 1,000 sealant sealants and resin-based sealants were placed on the occlusal
applications (95% CI, 72-255 fewer lesions) when using sealants surfaces of primary and permanent molars.50 When looking at
compared with using fluoride varnish after 2 to 3 years of follow-up. available data assessing the effect of GI sealants compared with
When assessing the effect of sealants compared with fluoride resin-based sealants in a population of patients with noncavitated
varnishes in a mixed population of patients with sound occlusal occlusal carious lesions, the data suggest that GI sealants may
surfaces and noncavitated occlusal carious lesions, sealants may increase the incidence of carious lesions by 53% (OR, 1.53; 95%
reduce the incidence of caries by 34%; however, this difference CI, 0.58-4.07); however, this difference was not statistically signi-
was not statistically significant (OR, 0.66; P=.30; 95% CI, 0.30- ficant (P=.39). When assessing retention, glass ionomer sealants
1.44). The guideline panel determined the overall quality of the may have 5 times greater risk of experiencing loss of retention
evidence for this comparison as low owing to serious issues of from the tooth compared with resin-based sealants after 2 to 3
risk of bias (unclear method for randomization and allocation years of follow-up (OR, 5.06; 95% CI, 1.81-14.13). The guide-
concealment) and inconsistency. No data on the effect of sealants line panel determined the overall quality of the evidence for this
versus fluoride varnish in adult patients were identified. comparison as very low owing to serious issues of risk of bias
Recommendation. The sealant guideline panel suggests the (unclear method for randomization and allocation concealment),
use of sealants compared with fluoride varnishes in primary inconsistency, and imprecision. No data on the effect of GI
and permanent molars, with both sound occlusal surfaces and versus resin-based sealants in adult patients were identified.
noncavitated occlusal carious lesions, in children and adoles-
cents. (Conditional recommendation, low-quality evidence.) Comparison 3.2. Glass ionomer sealants compared with resin-
Research priorities. modified GI sealants
• Although the analysis was stratified using 2 caries baseline Summary of findings. Data from 1 randomized controlled trial29
risks (30% caries prevalence in the article and 70% caries suggest that in children and adolescents with sound occlusal
prevalence in the tables), the guideline panel acknowledged surfaces the use of GI sealants compared with resin-modified GI
that clinicians lack a valid and reliable tool to conduct a sealants may increase the incidence of occlusal carious lesions
chairside caries risk assessment. There is a need for such a in permanent molars by 41% after 2 to 3 years of follow-up
tool to enable clinicians to understand the evidence in the (OR, 1.41; 95% CI, 0.65-3.07); however, this difference was
context of different caries risk estimations. not statistically significant (P=.38) (sTable 4, available in the
• The guideline panel suggests that more research should be supplemental data following references). In absolute terms, for a
conducted on other noninvasive approaches for caries arrest population with a caries baseline risk (prevalence) of 30%, we
in occlusal surfaces of primary and permanent molars (for are expecting to have 77 more carious lesions over 1,000 sealant
example, silver diamine fluoride). applications (95% CI, 82 fewer-268 more lesions) when using
GI sealants compared with using a resin-modified glass ionomer
Question 3. Which type of sealant material should be sealant after 2 to 3 years of follow-up; however, this difference
used in pits and fissures of occlusal surfaces of primary and was not statistically significant. When assessing retention, GI seal-
permanent molars on teeth deemed to have clinically sound ants would have 3 times greater risk of experiencing retention
occlusal surfaces or noncavitated carious lesions in children loss from the tooth compared with resin-modified glass ionomer
and adolescents? sealants after 2 to 3 years of follow-up (OR, 3.21; 95% CI,

1.87-5.51). The guideline panel determined the overall quality of the evidence for this comparison as very low owing to serious
of the evidence for this comparison as very low owing to serious issues of risk of bias (unclear method for randomization and
issues of risk of bias (unclear method for randomization and allocation concealment) and very serious issues of imprecision.
allocation concealment), and very serious issues of imprecision. No data on the effect of polyacid-modified resin versus resin-
No data on the effect of GI versus resin-modified GI sealants in based sealants in adult patients were identified.
adult patients were identified. Recommendation. The panel was unable to determine superi-
ority of 1 type of sealant over another owing to the very low
Comparison 3.3. Resin-modified glass ionomer sealants com- quality of evidence for comparative studies. The panel recom-
pared with polyacid-modified resin sealants. mends that any of the materials evaluated (for example,
Summary of findings. Data from 1 randomized controlled trial48 resin-based sealants, resin-modified GI sealants, GI cements, and
suggest that in children and adolescents with sound occlusal polyacid-modified resin sealants in no particular order) can be
surfaces, the use of resin-modified GI sealants compared with used for application in permanent molars with both sound
polyacid-modified GI sealants may reduce the incidence of occlusal surfaces and noncavitated occlusal carious lesions in
occlusal carious lesions in permanent molars by 56% after 2 children and adolescents. (Conditional recommendation, very
to 3 years of follow-up (OR, 0.44; 95% CI, 0.11-1.82); how- low-quality evidence.)
ever, this difference was not statistically significant (P=.26) Remarks.
(sTable 5, available in the supplemental data following refer- • The head-to-head analyses of all comparisons did not allow
ences). In absolute terms, for a population with a caries baseline the guideline panel to provide specific recommendations
risk (prevalence) of 30% this means that use of resin-modified using a hierarchy of effectiveness for the sealant materials.
GI sealants would prevent 141 carious lesions out of 1,000 sealant In addition, the quality of the evidence across head-to-head
applications (95% CI, 138 more-255 fewer lesions) compared comparisons was assessed to be low to very low at best. The
with the use of polyacid-modified resin sealants after 2 to 3 years guideline panel suggests that clinicians take into account the
of follow-up; but this difference was not statistically significant. likelihood of experiencing lack of retention when choosing
When assessing retention, resin-modified GI sealants may increase the type of sealant material most appropriate for a specific
the risk of loss of retention by 17% compared with polyacid- patient and clinical scenario. For example, in situations in
modified resin sealants after 2 to 3 years of follow-up (OR, 1.17; which dry isolation is difficult, such as a tooth that is not fully
95% CI, 0.52-2.66); however, this difference was not statistically erupted and has soft tissue impinging on the area to be sealed,
significant (P=.70). The guideline panel determined the overall then a material that is more hydrophilic (for example, GI)
quality of the evidence for this comparison as very low owing to would be preferable to a hydrophobic resin-based sealant.
serious issues of risk of bias (unclear method for randomization On the other hand, if the tooth can be isolated to ensure a
and allocation concealment) and very serious issues of imprecision. dry site and long-term retention is desired, then a resin-based
No data on the effect of resin-modified versus polyacid-modified sealant may be preferable.
resin sealants in adult patients were identified. • The lack of reporting in relation to resealing did not allow the
panel to include this as 1 more element for decision making.
Comparison 3.4. Polyacid-modified resin sealants com- However, it can be inferred from the data on retention loss
pared with resin-based sealants. that clinicians may need to monitor sealants showing a higher
Summary of findings. Data from 2 randomized controlled risk of experiencing retention loss more often.
trials48,51 suggest that in children and adolescents with sound • To obtain optimal levels of retention, the guideline panel
occlusal surfaces, the use of polyacid-modified resin sealants suggests clinicians carefully follow the manufacturers’ instruc-
compared with resin-based sealants may increase the incidence tions for each type of sealant material.
of occlusal carious lesions in permanent molars by 1% after 2 to
3 years of follow-up (OR, 1.01; 95% CI, 0.48-2.14); however, Research priorities.
this difference was not statistically significant (P=.97) (sTable 6, • The panel urges the research community to conduct high-
available in the supplemental data following references). In ab- quality randomized controlled trials to understand further the
solute terms, for a population with a caries baseline risk (prev- relative merits of the different types of sealant materials. Such
alence) of 30%, the use of polyacid-modified resin sealant would studies should meet the optimal information size17 to reduce
increase carious lesions by 2 out of 1,000 sealant applications the very serious issues of imprecision affecting this body of
(95% CI, 129 fewer-178 more lesions) compared with using a evidence.
resin-based sealant after 2 to 3 years of follow-up; however, this • New trials should improve reporting quality to allow the panel
difference was not statistically significant. When assessing the to conduct a more accurate assessment of the risk of bias.
outcome retention, polyacid-modified resin sealants seem to • Further research is needed to understand the role of different
reduce the risk of loss of retention by 13% compared with resin- types of sealant materials in the primary dentition and adult
based sealants after 2 to 3 years of follow-up (OR, 0.87; 95% CI, population.
0.12-6.21); however, this difference was not statistically signifi- • Although the analysis conducted was stratified using 2 caries
cant (P=.89). The guideline panel determined the overall quality baseline risks (30% caries prevalence in the article and 70%

caries prevalence in the tables), the guideline panel acknowl- clinical recommendations for the use of pit-and-fissure seal-
edged that clinicians lack a reliable and valid chairside tool ants: A report of the American Dental Association Council
to conduct a caries risk assessment. There is a need for such a on Scientific Affairs. J Am Dent Assoc 2008;139(3):257-68.
tool to enable clinicians to extrapolate the results from this 4. Young DA, Novy BB, Zeller GG, et al; American Dental
analysis to their patients in a more accurate manner. Association Council on Scientific Affairs. The American
• The poor quality or complete lack of reporting in relation to Dental Association Caries Classification System for clinical
resealing prevented the panel from using this information practice: a report of the American Dental Association Coun-
during the decision-making process. The panel highlighted cil on Scientific Affairs [published correction appears in
the need for improving the report of reapplication of sealants J Am Dent Assoc 2015;146(6):364-5]. J Am Dent Assoc
as 1 more relevant outcome in primary studies assessing the 2015;146(2):79-86.
effect of this intervention. 5. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries
and sealant prevalence in children and adolescents in the
Question 4. Are there any adverse events when using pit-and- United States, 2011-2012. Available at: "http://www.cdc.
fissure sealants? gov/nchs/products/databriefs/db191.htm". Accessed June
Summary of findings. There has been concern that dental seal- 9, 2016.
ants might exhibit adverse effects. This is primarily associated 6. U.S. Department of Health and Human Services. Oral
with bisphenol A (BPA). It has been suggested that the BPA Health in America: A Report of the Surgeon General Exec-
present in some sealants may have estrogenlike effects 52’ 53; utive Summary. Rockville, Md.: US Department of Health
however, the evidence does not support the transient effect of a and Human Services, National Institute of Dental and
small amount of BPA in placing patients at risk.54 Studies also Craniofacial Research, National Institutes of Health; 2000.
have evaluated the correlation of developing carious lesions in 7. Macek MD, Beltran-Aguilar ED, Lockwood SA, Malvitz
teeth with fully or partially lost sealants and found no greater DM. Updated comparison of the caries susceptibility of
risk than in teeth that had never been sealed.55 Two randomized various morphological types of permanent teeth. J Public
controlled trials measuring the occurrence of adverse effects asso- Health Dent 2003;63(3):174-82.
ciated with sealants found no events related to this outcome.27,56,57 8. Wright JT, Tampi MP, Graham L, et al. Sealants for prevent-
ing and arresting pit-and-fissure occlusal caries in primary
Conclusions and permanent molars: A systematic review of randomized
The evidence shows that sealants available in the U.S. market at controlled trials–a report of the American Dental Associa-
the time of this systematic review are an effective intervention for tion and the American Academy of Pediatric Dentistry.
reducing the incidence of carious lesions in the occlusal surfaces J Am Dent Assoc 2016;147(8):631-45.
of primary and permanent molars in children and adolescents 9. Splieth C, Förster M, Meyer G. Additional caries protection
compared with the nonuse of sealants or fluoride varnishes. This by sealing permanent first molars compared to fluoride
benefit is inclusive to both sound occlusal surfaces and non- varnish applications in children with low caries prevalence:
cavitated occlusal carious lesions. Clinicians should use these A 2-year results. Eur J Paediatr Dent 2001;2(3):133-7.
recommendations but consider carefully individual patient 10. Brouwers MC, Kerkvliet K, Spithoff K; AGREE Next Steps
factors, especially where the guideline panel offered conditional Consortium. The AGREE Reporting Checklist: A tool to
recommendations. In addition, sealant use should be increased improve reporting of clinical practice guidelines. BMJ 2016;
along with other preventive interventions to manage the caries 352:i1152.
disease process, especially in patients with an elevated risk of 11. Anusavice KJ, Shen C, Rawls HR. Phillips’ Science of
developing caries. Further research is needed to provide more Dental Materials. St. Louis, Mo.: Elsevier/Saunders; 2013.
risk-oriented recommendations, particularly regarding the devel- 12. Guyatt G, Oxman AD, Sultan S, et al. GRADE guidelines:
opment of a valid and reliable chairside tool for clinicians to 11. Making an overall rating of confidence in effect esti-
assess a patient’s caries risk. mates for a single outcome and for all outcomes. J Clin
Epidemiol 2013;66(2):151-7.
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Supplemental data
sTable 1. EVIDENCE PROFILE: SEALANTS COMPARED WITH NONUSE OF SEALANTS IN PIT-AND-FISSURE OCCLUSAL SURFACES
IN CHILDREN AND ADOLESCENTS *
QUALITY ASSESSMENT
1RRIVWXGLHV 6WXG\GHVLJQ 5LVNRIELDV ,QFRQVLVWHQF\ ,QGLUHFWQHVV ,PSUHFLVLRQ 2WKHUFRQVLGHUDWLRQV
&DULHVLQFLGHQFHIROORZXSUDQJH\ ‡
9 5DQGRPL]HGWULDOV Serious§ 1RWVHULRXV 1RWVHULRXV 1RWVHULRXV 1RQH

#
&DULHVLQFLGHQFHIROORZXSUDQJH\
3 5DQGRPL]HGWULDOV Serious§ Serious** 1RWVHULRXV 1RWVHULRXV 1RQH

#
&DULHVLQFLGHQFHIROORZXSUDQJH\RUPRUH
5DQGRPL]HGWULDOV Serious§ 1RWVHULRXV 1RWVHULRXV 1RWVHULRXV 1RQH
/DFNRIUHWHQWLRQIROORZXSUDQJH\
* Sources: Bravo and colleagues,s1 Liu and colleagues,s2 Mertz-Fairhurst and colleagues,s3 Splieth and colleagues,s4 Bojanini and colleagues,s5 Richardson
and colleagues,s6 Erdogan and colleagues,s7 Tagliaferro and colleagues,s8 and Pereira and colleagues.s9
** Unexplained heterogeneity (P<.0001, I 2 = 77%).
† The percentages (30% and 70%) indicate the control group baseline risk (caries prevalence).
†† 2 of 3 studies reported being conducted in water-fluoridated communities.
‡ A subgroup analysis conducted to determine whether there was a difference in the caries incidence depending on whether the sealant was placed in
patients with noncavitated carious lesions or deep fissures and pits, no caries in the occlusal surface, and a mix of caries free and noncavitated carious lesions,
showed no statistically significant differences (P=.58). Studies including a mixed population (recruiting both patients with noncavitated initial occlusal caries
and caries-free occlusal surfaces) showed a 76% reduction in caries incidence after 2- to 3-y follow-up (odds ratio, 0.24; 95% confidence interval, 0.19-0.30).
‡‡ 2 of 2 studies reported being conducted in water-fluoridated communities.
§ Most studies were classified as unclear for the "allocation concealment" and "masking" domains.
¶ 4 of 9 studies reported being conducted in water-fluoridated communities.
# Studies only reported data for this outcome in patients who were caries-free. Patients with noncavitated carious lesions or deep pits and fissures were
not included in the studies.
sTable 1 continued on the next page.

sTable 1. CONTINUED
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* Sources: Bravo and colleagues,s1 Liu and colleagues,s2 Mertz-Fairhurst and colleagues,s3 Splieth and colleagues,s4 Bojanini and colleagues,s5 Richardson
and colleagues,s6 Erdogan and colleagues,s7 Tagliaferro and colleagues,s8 and Pereira and colleagues.s9
** Unexplained heterogeneity (P<.0001, I 2 = 77%).
‡ A subgroup analysis conducted to determine whether there was a difference in the caries incidence depending on whether the sealant was placed in
patients with noncavitated carious lesions or deep fissures and pits, no caries in the occlusal surface, and a mix of caries free and noncavitated carious
lesions, showed no statistically significant differences (P=.58). Studies including a mixed population (recruiting both patients with noncavitated initial
occlusal caries and caries-free occlusal surfaces) showed a 76% reduction in caries incidence after 2- to 3-y follow-up (odds ratio, 0.24; 95% confidence
interval, 0.19-0.30).
¶ 4 of 9 studies reported being conducted in water-fluoridated communities.
# Studies only reported data for this outcome in patients who were caries-free. Patients with noncavitated carious lesions or deep pits and fissures were
not included in the studies.

sTable 2. EVIDENCE PROFILE: SEALANTS COMPARED WITH FLUORIDE VARNISHES IN PIT-AND-FISSURE OCCLUSAL SURFACES
IN CHILDREN AND ADOLESCENTS*
QUALITY ASSESSMENT
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3$7,(1761 EFFECT QUALITY IMPORTANCE
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LQWHUYDO
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‡‡ IHZHUSHUIHZHU /RZ &ULWLFDO
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§§ IHZHUSHUIHZHU /RZ &ULWLFDO
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,QFOXGLQJDOOVHDODQWPDWHULDOW\SHVDQGWRRWKSUHSDUDWLRQWHFKQLTXHVRIVHDODQWVZHUHIXOO\UHWDLQHG 0RGHUDWH ,PSRUWDQW

DW\DQGZHUHIXOO\RUSDUWLDOO\UHWDLQHGDW\DW\RIDOOVHDODQWVZHUHIXOO\UHWDLQHGDQG
ZHUHIXOO\RUSDUWLDOO\UHWDLQHGDW\
* Sources: Houpt and colleagues,s10 Bravo and colleagues,s1 and Liu and colleagues.s2
** The studies only reported the outcome in patients who were caries-free.
†† Unexplained heterogeneity (P=.03, I 2=80%).
‡ A subgroup effect was identified for this outcome (P=.04). Patients who were caries-free (odds ratio, 0.19; 95% confidence interval, 0.07-0.47) and
mixed population (odds ratio, 0.66; 95% confidence interval, 0.30-1.44).
§§ The study reported being conducted in water-fluoridated communities.
¶ Unexplained heterogeneity (P=.0002, I 2=88%).
# 2 of 3 studies reported being conducted in water-fluoridated communities.

sTable 3. EVIDENCE PROFILE: GLASS IONOMER SEALANTS COMPARED WITH RESIN-BASED SEALANTS IN PIT-AND-FISSURE
OCCLUSAL SURFACES IN CHILDREN AND ADOLESCENTS *
QUALITY ASSESSMENT
&DULHVLQFLGHQFHIROORZXSUDQJH\‡,§
10 5DQGRPL]HGWULDOV Serious¶ Serious# 1RWVHULRXV Serious** 1RQH
&DULHVLQFLGHQFHIROORZXSUDQJH\‡‡
5DQGRPL]HGWULDOV Serious§§ 1RWVHULRXV 1RWVHULRXV 9HU\VHULRXV¶¶ 1RQH
&DULHVLQFLGHQFHIROORZXSUDQJH\URUPRUH ±QRWUHSRUWHG

—## — — — — — —
/DFNRIUHWHQWLRQIROORZXSUDQJH\U
10 5DQGRPL]HGWULDOV Serious ¶ Serious*** 1RWVHULRXV 1RWVHULRXV 1RQH

/DFNRIUHWHQWLRQIROORZXSUDQJH\U ±QRWUHSRUWHG
5DQGRPL]HGWULDOV Serious§§ 1RWVHULRXV 1RWVHULRXV Serious††† —
/DFNRIUHWHQWLRQ±QRWUHSRUWHG
— — — — — — —
*ODVVLRQRPHU 5HVLQEDVHG 5HODWLYHRGGVUDWLR $EVROXWH

VHDODQWV VHDODQWV† FRQ¿GHQFH FRQ¿GHQFHLQWHUYDO
LQWHUYDO
†† IHZHUSHUPRUHIHZHU 9HU\ORZ &ULWLFDO
IHZHUSHUPRUHIHZHU
IHZHUSHUPRUHIHZHU
IHZHUSHUIHZHU 9HU\ORZ &ULWLFDO
IHZHUSHUIHZHU
IHZHUSHUIHZHU
— — — — — &ULWLFDO
PRUHSHUPRUH /RZ ,PSRUWDQW
PRUHSHUPRUHIHZHU /RZ ,PSRUWDQW
— — — — — ,PSRUWDQW
* Sources: Chen and colleagues,s11,s12 Chen and Liu,s13 Amin,s14 Antonson and colleagues,s15 Arrow and Riordan,s16 Baseggio and colleagues,s17 Pardi and
colleagues,s18 Guler and Yilmaz,s19 Dhar and Chen,s20 and Haznedaroglu and Guner.s21
** 95% confidence interval suggests large benefit and a large harm (95% confidence interval, 68% reduction-57% increase).
*** Unexplained heterogeneity (P≤ .00001, I 2=97%).
††† 95% confidence interval suggests a large benefit and a large harm (95% confidence interval, 85% reduction-2,695% increase).
‡ A subgroup analysis conducted to determine whether there was a difference in the caries incidence depending on whether the sealant was placed
in noncavitated carious lesions or deep fissures and pits, no caries in the occlusal surface, and a mix of caries free and noncavitated carious lesions,
showed no statistically significant differences (odds ratio, 1.53; 95% confidence interval, 0.58-4.07; P=.19).
‡‡ Only 2 studies reported this outcome. No subgroup analysis was conducted.
§ One additional study including 200 participants that was not included in the meta-analysis due to the data presentation failure to show a clinically
or statistically significant difference in caries incidence when glass ionomer sealants and resin-based sealants were placed in the occlusal surfaces of
primary and permanent teeth.
§§ The "randomization" and "allocation concealment" domains were classified as "unclear" risk of bias for most studies.
¶ Most studies were classified as unclear for the “allocation concealment” and “masking” domains.
¶¶ 95% confidence interval suggests a large benefit and a large harm (95% confidence interval, 96% reduction-0% increase).
# Unexplained heterogeneity (P<.00001, I 2=81%). ## Dashes indicate data not available.

sTable 4. EVIDENCE PROFILE: GLASS IONOMER SEALANTS COMPARED WITH RESIN-MODIFIED GLASS IONOMER SEALANTS
IN PIT-AND-FISSURE OCCLUSAL SURFACES IN CHILDREN AND ADOLESCENTS*
QUALITY ASSESSMENT
&DULHVLQFLGHQFHIROORZXSUDQJH\‡
1 5DQGRPL]HGWULDOV Serious§ 1RWVHULRXV 1RWVHULRXV 9HU\VHULRXV¶ 1RQH
&DULHVLQFLGHQFHIROORZXSUDQJH\±QRWUHSRUWHG

—** — — — — — —
&DULHVLQFLGHQFHIROORZXSUDQJH\RUPRUH±QRWUHSRUWHG

— — — — — — —
/DFNRIUHWHQWLRQIROORZXSUDQJH\±QRWUHSRUWHG

— — — — — — —
/DFNRIUHWHQWLRQIROORZXSUDQJH\RUPRUH±QRWUHSRUWHG

— — — — — — —
*ODVVLRQRPHU 5HVLQPRGL¿HG 5HODWLYHRGGVUDWLR $EVROXWH

VHDODQWV JODVVLRQRPHU FRQ¿GHQFH FRQ¿GHQFHLQWHUYDO
VHDODQWV LQWHUYDO
# PRUHSHUIHZHUPRUH 9HU\ORZ &ULWLFDO
PRUHSHUIHZHUPRUH
PRUHSHUIHZHUPRUH
— — — — — &ULWLFDO
— — — — — &ULWLFDO
PRUHSHUPRUH 0RGHUDWH ,PSRUWDQW
* Source: Pereira and colleages.s9

** Dashes indicate data not available.
‡ Only 1 study reported this outcome. No subgroup analysis was included.
§ All domains were classified as unclear, including the "allocation concealment" and "masking" domains.
¶ The 95% confidence interval suggests an appreciable benefit and an appreciable harm (95% confidence interval, 45% reduction-207% increase in
caries incidence).
# The study was conducted in water-fluoridated communities.

sTable 5. EVIDENCE PROFILE: RESIN-MODIFIED GLASS IONOMER SEALANTS COMPARED WITH POLYACID-MODIFIED RESIN
SEALANTS IN PIT-AND-FISSURE OCCLUSAL SURFACES IN CHILDREN AND ADOLESCENTS*
QUALITY ASSESSMENT
1 5DQGRPL]HGWULDOV Serious§ 1RWVHULRXV 1RWVHULRXV 9HU\VHULRXV¶ 1RQH
&DULHVLQFLGHQFHIROORZXSUDQJH\QRWUHSRUWHG

—** — — — — — —
&DULHVLQFLGHQFHIROORZXSUDQJH\RUPRUHQRWUHSRUWHG

— — — — — — —
1 5DQGRPL]HGWULDOV Serious§ 1RWVHULRXV 1RWVHULRXV 9HU\VHULRXV†† 1RQH
/DFNRIUHWHQWLRQIROORZXSUDQJH\QRWUHSRUWHG

— — — — — — —
/DFNRIUHWHQWLRQIROORZXSUDQJH\RUPRUHQRWUHSRUWHG

— — — — — — —
5HVLQPRGL¿HG 3RO\DFLG 5HODWLYHRGGVUDWLR $EVROXWH

JODVVLRQRPHU PRGL¿HGUHVLQ FRQ¿GHQFH FRQ¿GHQFHLQWHUYDO
VHDODQWV VHDODQWV† LQWHUYDO
# IHZHUSHUPRUHIHZHU 9HU\ORZ &ULWLFDO
IHZHUSHUPRUHIHZHU
IHZHUSHUPRUHIHZHU
— — — —
— — — —
PRUHSHUIHZHUPRUH 9HU\ORZ ,PSRUWDQW
— — — —
— — — — —
* Source: Pardi and colleagues.s18

†† 95% confidence interval suggests a large benefit and a large harm (95% confidence interval, 48% reduction-166% increase). Only 27 events are
informing this outcome.
‡ Only 1 study reported this outcome. No subgroup analysis was conducted.
§ All risk of bias domains were classified as unclear.
¶ 95% confidence interval suggests a large benefit and a large harm (95% confidence interval, 89% reduction-82% increase). Only 9 events are informing
this outcome.
# The study was conducted in water-fluoridated communities.

sTable 6. EVIDENCE PROFILE: POLYACID-MODIFIED RESIN SEALANTS COMPARED WITH RESIN-BASED SEALANTS IN PIT-AND-
FISSURE OCCLUSAL SURFACES IN CHILDREN AND ADOLESCENTS*
QUALITY ASSESSMENT
1RRI6WXGLHV 6WXG\'HVLJQ 5LVNRI%LDV ,QFRQVLVWHQF\ ,QGLUHFWQHVV ,PSUHFLVLRQ 2WKHU&RQVLGHUDWLRQV
5DQGRPL]HGWULDOV Serious§ 1RWVHULRXV 1RWVHULRXV 9HU\VHULRXV¶ 1RQH
&DULHVLQFLGHQFHIROORZXSUDQJH\QRWUHSRUWHG
—** — — — — — —
&DULHVLQFLGHQFHIROORZXSUDQJH\RUPRUHQRWUHSRUWHG
— — — — — — —
5DQGRPL]HGWULDOV Serious§ Serious†† 1RWVHULRXV Serious‡‡ 1RQH
/DFNRIUHWHQWLRQIROORZXSUDQJH\QRWUHSRUWHG

— — — — — — —
/DFNRIUHWHQWLRQIROORZXSUDQJH\RUPRUHQRWUHSRUWHG

— — — — — — —
3RO\DFLGPRGL¿HG 5HVLQEDVHG 5HODWLYHRGGVUDWLR $EVROXWH

UHVLQVHDODQWV VHDODQWV† FRQ¿GHQFH FRQ¿GHQFHLQWHUYDO
LQWHUYDO
# WR PRUHSHUIHZHUPRUH 9HU\ORZ &ULWLFDO
PRUHSHUIHZHUPRUH
PRUHSHUPRUHIHZHU
— — — — —
— – — — —
IHZHUSHUIHZHUPRUH 9HU\ORZ ,PSRUWDQW
— — — — —
— — — — —
* Sources: Gungor and colleaguess22 and Pardi and colleagues.s18

†† Unexplained heterogeneity (P<.00001, I 2=97%).
‡ The studies only reported the outcome in patients who were caries-free. No subgroup analysis was conducted.
‡‡ 95% confidence interval suggests a large benefit and a large harm (95% confidence interval, 88% reduction-521% increase).
§ The 2 studies were classified as "unclear" risk of bias for the domain "allocation concealment".
¶ 95% confidence interval suggests a large benefit and a large harm (95% confidence interval, 52% reduction-114% increase).
# 1of 2 studies reported being conducted in water-fluoridated communities.

Supplementary references s12. Chen X, Du M, Fan M, Mulder J, Huysmans MC, Frencken

s1. Bravo M, Llodra JC, Baca P, Osorio E. Effectiveness of JE. Effectiveness of two new types of sealants: retention
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Oral Epidemiol 1996;24(1):42-6. sealant in children at high and low risk of caries. Dent
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Giustina VE, Brooks JD. A comparative clinical study of month clinical evaluation of fissure sealants on partially
two pit and fissure sealants: 7-year results in Augusta, GA. erupted permanent first molars: glass ionomer versus resin-
J Am Dent Assoc 1984;109(2):252-5. based sealant. J Am Dent Assoc 2012;143(2):115-22.
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by sealing permanent first molars compared to fluoride var- of a GIC and a resin-based fissure sealant. Community Dent
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2-year results. Eur J Paediatr Dent 2001;2(3):133-8. s17. Baseggio W, Naufel FS, Davidoff DC, Nahsan FP, Flury S,
s5. Bojanini J, Garces H, McCune RJ, Pineda A. Effectiveness Rodrigues JA. Caries-preventive efficacy and retention of a
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Assoc 1980;46(4):259-60. Clinical evaluation of three different materials used as pit
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ized pit and fissure sealant: Results after 4.5 years. J Paediatr 2005;29(2):133-7.
Dent 1987;3:11-3. s19. Guler C, Yilmaz Y. A two-year clinical evaluation of glass
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da Silva SR, Pereira AC. Occlusal caries prevention in high Dent 2013;37(3):263-7.
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Mater 2012;28(5):554-60.

CLINICAL PRACTICE GUIDELINES: VITAL PULP THERAPIES
Use of Vital Pulp Therapies in Primary Teeth with

Deep Caries Lesions
Developed by
How to Cite: Dhar V, Marghalani AA, Crystal YO, Kumar A, Ritwik P,
Tulunoglu O, Graham L. Use of vital pulp therapies in primary teeth with
Issued deep caries lesions. Pediatr Dent 2017;39(5):E146-E159.
2017
Abstract
Purpose: This manuscript presents evidence-based guidance on the use of vital pulp therapies for treatment of deep caries lesions in children.
A guideline panel convened by the American Academy of Pediatric Dentistry formulated evidence-based recommendations on three vital
pulp therapies: indirect pulp treatment (IPT; also known as indirect pulp cap), direct pulp cap (DPC), and pulpotomy.
Methods: The basis of the guideline’s recommendations was evidence from “Primary Tooth Vital Pulp Therapy: A Systematic Review and Meta-
Analysis.” (Pediatr Dent 2017;15;39[1]:16-23.) A systematic search was conducted in PubMed /MEDLINE, Embase , Cochrane Central Register of
® ®
Controlled Trials, and trial databases to identify randomized controlled trials and systematic reviews addressing peripheral issues of vital pulp
therapies such as patient preferences of treatment and impact of cost. Quality of the evidence was assessed through the Grading of Recommen-
dations Assessment, Development, and Evaluation approach; the evidence-to-decision framework was used to formulate a recommendation.
Results: The panel was unable to make a recommendation on superiority of any particular type of vital pulp therapy owing to lack of studies
directly comparing these interventions. The panel recommends use of mineral trioxide aggregate (MTA) and formocresol in pulpotomy treat-
ments; these are recommendations based on moderate-quality evidence at 24 months. The panel made weak recommendations regarding
choice of medicament in both IPT (moderate-quality evidence [24 months], low quality evidence [48 months]) and DPC (very-low quality
evidence [24 months]). Success of both treatments was independent of type of medicament used. The panel also recommends use of ferric
sulfate (low-quality evidence), lasers (low-quality evidence), sodium hypochlorite (very low-quality evidence), and tricalcium silicate (very low-
quality evidence) in pulpotomies; these are weak recommendations based on low-quality evidence. The panel recommended against the
use of calcium hydroxide as pulpotomy medicament in primary teeth with deep caries lesions.
Conclusions and practical implications: The guideline intends to inform the clinical practices with evidence-based recommendations on vital
pulp therapies in primary teeth with deep caries lesions. These recommendations are based upon the best available evidence to-date.
KEYWORDS: PULPOTOMY, PULP THERAPY, VITAL PULP THERAPY, INDIRECT PULP TREATMENT, INDIRECT PULP CAP, DIRECT PULP CAP, FORMOCRESOL, MINERAL
TRIOXIDE AGGREGATE, FERRIC SULFATE, SODIUM HYPOCHLORITE, CALCIUM HYDROXIDE, TRICALCIUM SILICATE
Scope and purpose alternates such as bonding agents, mineral trioxide aggregate
The American Academy of Pediatric Dentistry (AAPD) intends (MTA), or formocresol; and pulpotomies using formocresol,
this guideline to aid clinicians in optimizing patient care when MTA, ferric sulfate (FS), sodium hypochlorite (NaOCl), lasers,
choosing vital pulp therapies to treat children with deep caries calcium hydroxide, or tricalcium silicate. In addition to the re-
lesions ‡ 1 in vital primary teeth. Carious primary teeth diagnosed ported adverse events, the evidence on outcome moderators
with a normal pulp requiring pulp therapy or with reversible such as type of final restorations and use of rubber dam was
pulpitis should be treated with vital pulp procedures.2-6 Cur- reviewed for this guideline.
rently, there are three vital pulp therapy (VPT) options for
treatment of deep dentin caries lesions approximating the pulp
in vital primary teeth: (1) indirect pulp treatment (IPT), also ABBREVIATIONS
known as indirect pulp cap;7 (2) direct pulp cap (DPC); and AAPD: American Academy of Pediatric Dentistry. AGREE: Appraisal of
(3) pulpotomy.2,7 Guidelines Research and Evaluation. CDC: Centers for Disease Control
and Prevention. CH: Calcium Hydroxide. DPC: Direct pulp cap. DQA:
For the purpose of this guideline, various interventions for Dental Quality Alliance. EBDC: Evidence-Based Dentistry Committee.
vital pulp therapy were evaluated, including indirect pulp treat- FS: Ferric sulfate. GRADE: Grading of Recommendations Assessment,
ment using calcium hydroxide and alternates such as bonding Development and Evaluation. IPT: Indirect pulp therapy. M. abscessus:
Mycobacterium abscessus. MTA: Mineral trioxide aggregate. NaOCl:
agents/liners; direct pulp cap using calcium hydroxide and
Sodium hypochlorite. NGC: National Guideline Clearinghouse. NNT:
Number needed to treat. PICO: Population Intervention Control Out-
come. RR: Relative risk. SSC: Stainless steel crowns. USDHHS: U.S.
‡ A caries lesion is a detectable change in the tooth structure that results from the Department of Health and Human Services. VPT: Vital pulp therapy.
biofilm-tooth interactions occurring due to the disease caries. It is the clinical manifes-
tation (sign) of the caries process.

The current recommendation supersedes the previous pulp trials and systematic reviews addressing peripheral issues not
therapy guideline2 on the vital pulp therapies in primary teeth covered by the review, such as patient preferences and impact
with deep caries lesions and does not cover non-vital pulp of cost. The search strategy was updated by one of the authors
therapies, pulp therapy for immature permanent teeth, or pulp (LG). Title and abstract and, when warranted, full-text of
therapy for primary teeth with traumatic injuries. This clinical studies were reviewed in duplicate by workgroup members
practice guideline adheres to the Appraisal of Guidelines Research (VD, YC). Appendix for search strategy appears after References.
and Evaluation (AGREE) reporting checklist.8 Assessment of the evidence. The main strength of this
Clinical questions addressed. The panel members used guideline is that it is based on a systematic review that adhered
the Population, Intervention, Control, and Outcome (PICO) to the standards of the Cochrane Handbook for Systematic Re-
formulation to develop the following clinical questions that will views of Interventions10 and assessed the quality of the evidence
aid clinicians in the use of vital pulp therapies in primary teeth using the Grades of Recommendation Assessment, Development,
with deep caries lesions. and Evaluation (GRADE) approach.11
1. In vital primary teeth with deep caries lesions requiring Weakness of this guideline are inherent to the limitations
pulp therapy, is one particular therapy (indirect pulp found in the systematic review 9 upon which this guideline is
treatment, direct pulp cap, pulpotomy) more successful * based. Limitations include failure to review non-English lan-
than others? guage studies other than those in Spanish or Portuguese, and
2. In vital primary teeth treated with indirect pulp treatment that the recommendations are based on combined data from
due to deep caries lesions, does the choice of medicament studies of differing risks of bias.
affect success*? Formulation of the recommendations. The panel evalu-
3. In vital primary teeth with deep caries lesions treated with ated and voted on the level of certainty of the evidence using
direct pulp cap due to pulp exposure (one mm or less) the GRADE approach.11 The GRADE approach recognizes the
encountered during carious dentin removal, does the choice evidence quality (Table 1)11 and certainty as high, moderate, low,
of medicament affect success*? and very low, based on serious or very serious issues including
4. In vital primary teeth with deep caries lesions treated with risk of bias, imprecision, inconsistency, indirectness of evidence,
pulpotomy due to pulp exposure during caries removal, and publication bias. To formulate the recommendations, the
does the choice of medicament or technique affect success*? panel used an evidence-to-decision framework including do-
mains such as priority of the problem, certainty in the evidence,
* Success was defined as overall success simultaneously observed both clinically balance between desirable and undesirable consequences, and
and radiographically. patients’ values and preferences. The strength of a recommen-
dation was assessed to be either strong or conditional, which
Methods presents different implications for patients, clinicians, and policy
The AAPD previously published a guideline on pulp therapy makers (Table 2).12
entitled “Pulp Therapy for Primary and Immature Permanent The guidelines were formulated via teleconferences and
Teeth”, last revised in 2014. 2 Evidence from “Primary Tooth online forum discussion with members of the workgroup. The
Vital Pulp Therapy: A Systematic Review and Meta-Analysis”9 is panel members discussed all recommendations and issues sur-
the basis for the current guideline’s recommendations. rounding the topic under review, and all significant topics such
Search strategy and evidence inclusion criteria. Since it as recommendations were voted upon anonymously.
was decided a priori to use the aforementioned systematic re- Understanding the recommendations. These clinical prac-
view,9 multiple literature searches were conducted in PubMed / ® tice guidelines provide recommendations for vital pulp therapies
®
MEDLINE, Embase , Cochrane Central Register of Controlled
Trials, and trial databases to identify randomized controlled
in primary teeth with deep caries lesions.
Table 1. QUALITY OF EVIDENCE GRADES †

Grade Definition
High We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility
that it is substantially different.
Low Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very Low We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
† Quality of evidence is a continuum; any discrete categorization involves some degree of arbitrariness. Nevertheless, advantages of simplicity, transparency, and vividness outweigh these limitations.
Reprinted with permission. Quality of evidence and strength of recommendations. GRADE Handbook: Handbook for grading the quality of evidence and the strength of recommendations using
the GRADE approach. Update October 2013. Available at: “http://gdt.guidelinedevelopment.org/app/handbook/handbook.html”.

For patients Most individuals in this situation would want the recommended The majority of individuals in this situation would want the suggested
course of action and only a small proportion would not. course of action, but many would not.
For clinicians Most individuals should receive the recommended course of Recognize that different choices will be appropriate for different pa-
action. Adherence to this recommendation according to the tients, and that you must help each patient arrive at a management
guideline could be used as a quality criterion or performance decision consistent with her or his values and preferences. Decision
indicator. Formal decision aids are not likely to be needed to aids may well be useful helping individuals making decisions con-
help individuals make decisions consistent with their values sistent with their values and preferences. Clinicians should expect to
and preferences. spend more time with patients when working towards a decision.
For policy The recommendation can be adapted as policy in most situations Policymaking will require substantial debates and involvement of
makers including for the use as performance indicators. many stakeholders. Policies are also more likely to vary between re-
gions. Performance indicators would have to focus on the fact that
adequate deliberation about the management options has taken place.
Reprinted with permission. GRADE Handbook: Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. Update October 2013.
Available at: “http://gdt.guidelinedevelopment.org/app/handbook/handbook.html”.
A strong recommendation implies in most situations that therapy over the others. The panel noted similar success rates
clinicians should follow the suggested intervention. A conditional among the three therapies and suggests that the choice of pulp
recommendation indicates that while the clinician may want therapy in vital primary teeth with deep caries lesions should
to follow the suggested intervention, the panel recognizes that be based on a biological approach for caries-affected dentin
different choices may be appropriate for individual patients.13 removal, pulp exposures (if any), reported adverse effects (if any),
Table 3 shows a summary of the recommendations included in clinical expertise, and patient preferences.
this guideline. Research considerations: There is a dearth of research com-
paring types of vital pulp therapies (IPT vs. DPC vs. pulpotomy)
Recommendations * in primary teeth. The panel urges researchers to conduct well-
Question 1. In vital primary teeth with deep caries lesions re- designed randomized clinical trials comparing the outcomes
quiring pulp therapy, is one particular therapy (IPT, DPC, of IPT, DPC, and pulpotomies in primary teeth with deep
pulpotomy) more successful than others? caries lesions.
Recommendation: The panel was unable to make a recom-
menda tion on superiority of any particular type of vital pulp Question 2. In vital primary teeth treated with indirect pulp
therapy owing to lack of studies directly comparing these treatment due to deep caries lesions, does the choice of medi-
interventions. cament affect success?
Summary of findings: The systematic review9 did not offer Recommendation: The panel found that the success of IPT
any direct comparison between IPT, DPC, and pulpotomy bein vital primary teeth with deep caries lesions was independent
cause of paucity of studies directly comparing these interven- of the type of medicament used, and therefore recommends
tions. Out of the six studies on IPT3-6,14,15, three studies3,5,14 with that clinicians choose the medicament based on individual
a follow up of 24 months, presented an overall success rate of preferences. (Conditional recommendation, moderate-quality
94.4 percent (95 percent confidence interval [95% CI]=84.9 evidence [24 months], Low quality evidence [48 months])
to 98.0). For DPC, out of the four studies16-19 evaluated, the Summary of findings: The systematic review 9 of six stud-
three studies16,18,19 with a follow up of 24 months, showed an ies 3-6,14,15
compared IPT success using calcium hydroxide liners
overall success of 88.8 percent (95% CI=73.3 to 95.8). For versus bonding agent liners. The meta-analysis showed that
pulpotomy, 12 studies20-31 with a follow up of 24 months, showed the liner had no effect on IPT success at 24 months (P=0.88)
an overall success of 82.6 percent (95% CI=75.8 to 87.8). 9 (relative risks [RR] 1.00, 95% CI=0.98 to 1.03 and 48 months
Forty-eight-month outcome data were available only for IPT follow-up [RR 1.10, 95% CI=0.92 to 1.32]) (P=0.31) (Table 5).9
and showed that the overall success rate decreased to 83.4 The quality of the evidence for liners was best at 24 months,
percent (95% CI=72.9 to 90.4). 9 The guideline panel was and was assessed as moderate due to small sample sizes. At 48-
unable to determine superiority of any one type of vital pulp months, the quality of evidence was assessed as low due to
the very small sample size issues. The summary of findings for
IPT is included in Table 4.9
* For each of the following questions, success was definied as overall sucess simul-
taneously observed both clinically and radiographically.

Table 3. SUMMARY OF CLINICAL RECOMMENDATION ON VITAL PULP THERAPIES IN PRIMARY TEETH WITH DEEP CARIES
Question Recommendation Quality of evidence Strength of

(follow-up duration) recommendation
In vital primary teeth with deep caries lesions re- The panel was unable to make a recommendation on ---- -----
quiring pulp therapy, is one particular therapy (IPT, superiority of any particular type of vital pulp therapy
DPC, pulpotomy) more successful* than others? owing to lack of studies directly comparing these
interventions.
Panel noted the high success rates among IPT, DPC,
and pulpotomy and recommends that the choice of
pulp therapy in vital primary teeth with deep caries
lesions should be based on a biologic approach. ^
In vital primary teeth treated with indirect pulp The panel found that the success of IPT in vital pri- Moderate (24 mo.) Conditional
treatment (IPT) due to deep caries lesions, does the mary teeth with deep caries lesions is independent
choice of medicament affect success*? of the type of medicament used, and therefore con- Low (48 mo.) Conditional
ditionally recommends that clinicians choose the
medicament based on individual preferences. †
In vital primary teeth with deep caries lesions treated The panel found that in vital primary teeth with deep Very Low (24 mo.) Conditional
with DPC due to pulp exposure (one mm or less) caries lesions treated with DPC due to pulp exposure
encountered during carious dentin removal, does (one mm or less) encountered during carious dentin
the choice of medicament affect success*? removal, the success of DPC is independent of the
type of medicament used, and therefore condition-
ally recommends that clinicians choose the medica-
ment based on individual preferences. ‡
In vital primary teeth with deep caries lesions treated The panel strongly recommends the use of MTA in Moderate (24 mo.) Strong
with pulpotomy due to pulp exposure during caries vital primary teeth with deep caries lesions treated
removal, does the choice of medicament or tech- with pulpotomy due to pulp exposure during carious
nique affect success*? dentin removal.
The panel strongly recommends the use of formocresol Moderate (24 mo.) Strong
in vital primary teeth with deep caries lesions treated
with pulpotomy due to pulp exposure during carious
dentin removal.
The panel conditionally recommends the use of ferric Low (24 mo.) Conditional
sulfate in vital primary teeth with deep caries lesions
treated with pulpotomy due to pulp exposure during
carious dentin removal.
The panel conditionally recommends against the use Low (24 mo.) Conditional
of calcium hydroxide in vital primary teeth with
deep caries lesions treated with pulpotomy due to pulp
exposure during carious dentin removal.
The panel conditionally recommends the use of lasers Low (18 mo.) Conditional
in vital primary teeth with deep caries lesions treated
with pulpotomy due to pulp exposure during carious
dentin removal.
The panel conditionally recommends the use of Very Low (18 mo.) Conditional
sodium hypochlorite in vital primary teeth with deep
caries lesions treated with pulpotomy due to pulp
exposure during carious dentin removal.
The panel conditionally recommends the use of tri- Very Low (12 mo.) Conditional
calcium silicate in vital primary teeth with deep caries
lesions treated with pulpotomy due to pulp exposure
during carious denitn removal.
IPT= Indirect pulp treatment; DPC= Direct pulp cap; MTA= Mineral trioxide aggregate.
* Success was defined as overall success simultaneously observed both clinically and radiographically.
^ The panel suggests clinicians take the most biological approach considering caries-affected dentin removal, pulp exposures (if any), reported adverse effects (if any),
clinical expertise, and patient preferences.
† The medicaments evaluated were calcium hydroxide and alternates such as bonding agents/liners.
‡ The medicaments evaluated were calcium hydroxide and alternates such as dentin bonding agents, MTA, and formocresol.
Quality of evidence was downgraded by one level based on GRADE guidelines on handling indirect comparisons.

Question 3. In vital primary teeth with deep caries lesions Question 4. In vital primary teeth with deep caries treated
treated with direct pulp cap due to pulp exposure (one mm with pulpotomy due to pulp exposure during caries removal,
or less) encountered during carious dentin removal, does the does the choice of medicament or technique affect success?
choice of medicament affect success? Recommendations:
Recommendation: The panel found that in vital primary • The panel recommends the use of MTA in vital primary
teeth with deep caries lesions treated with DPC due to pulp teeth with deep caries lesions treated with pulpotomy due
exposure (one mm or less) encountered during caries removal, to pulp exposure during carious dentin removal. (Strong
the success of DPC was independent of the type of medica- recommendation, moderate-quality evidence)
ment (dentin bonding agents, MTA, and formocresol), and • The panel recommends the use of formocresol in vital pri-
therefore recommends that clinicians choose the medicament mary teeth with deep caries lesions treated with pulpotomy
based on individual preferences. (Conditional recommendation, due to pulp exposure during carious dentin removal.
very-low quality evidence.) (Strong recommendation, moderate-quality evidence)
Summary of findings: The systematic review9 of three DPC • The panel recommends the use of FS in vital primary teeth
studies compared calcium hydroxide versus alternative direct with deep caries lesions treated with pulpotomy due to
capping agents after 24-months (dentin bonding agents 16, pulp exposure during carious dentin removal. (Conditional
MTA18, and formocresol19). At 24-month follow-up, the meta- recommendation, low-quality evidence)
analysis showed the capping agent had no effect on success • The panel recommends the use of lasers in vital pri-
(RR 1.05, 95% CI=0.89 to 1.25) (P=0.56).9 The quality of the mary teeth with deep caries lesions treated with pulpotomy
evidence for whether DPC capping agent affected success at 24 due to pulp exposure during carious dentin removal.
months was assessed as very low because of the high degree of (Conditional recommendation, low-quality evidence)
heterogeneity in the studies (I2=83 percent) and small sample • The panel recommends the use of NaOCl in vital pri-
size. All the three DPC studies involved immediate placement mary teeth with deep caries lesions treated with pulpotomy
of the final restoration.9 The summary of findings for DPC is due to pulp exposure during carious dentin removal.
included in Table 5. (Conditional recommendation, very low-quality evidence)
Table 4. SUMMARY OF FINDINGS FOR IPT

Outcomes Illustrative comparative risks (95% CI) Relative effect (95% CI) Number of Quality of the
participants evidence (GRADE)
Overall success CH IPT success= 91.6% (74.3 to 97.6) RR 1.00 (0.98 to 1.03) P=0.88 3 studies Moderate
at 24 mos. IPT without CH success= 96.8% All liners equally successful with 319 teeth
(79.3 to 99.6) NNT= Not significant
Overall success CH IPT success= 78.5% (61.2 to 89.5) RR 1.10 (0.92 to 1.32) favors 3 studies Low
at 48 mos. IPT without CH success= 88.2% IPT without CH P=0.31 with 81 teeth
Comments: The 24 and 48 month studies used CH as one liner and the alternatives included Scotchbond™3,4, Clearfill SE™14, Vitremer™5, Prime &
® ®
Bond , and Xeno 13.
CH= Calcium hydroxide; IPT= Indirect pulp treatment; NNT= Number needed to treat; RR= Relative risks.
Table 5. SUMMARY OF FINDINGS FOR DPC
Outcomes Illustrative comparative risks (95% CI) Relative effect (95% CI) Number of Quality of the
participants evidence (GRADE)
Overall success CH DPC success= 91.1% (41.7 to 99.3) RR 1.05 (0.89 to 1.25) favoring 3 studies Very low
at 24 mos. Alternative DPC success= 88.5% the alternative DPC P=0.56 with 262 teeth
Comments: Distribution of teeth in the 24-month studies were: 100 teeth in the CH arms and 162 teeth in the alternative arms (60 FC teeth19,
® ®
80 NaOCl rinse followed by Prime & Bond or Xeno 16, and 22 MTA18.
All three 24-month DPC studies involved immediate placement of the final restoration (Aminabadi19 2010 had 120 teeth SSC’s, Demir16 100 teeth
amalgam or compomer surface sealed, Tuna18 42 teeth Kalzinol base and amalgam).
CH= Calcium hydroxide; DPC= Direct pulp cap; NaOCl= Sodium hypochlorite; NNT= Number needed to treat; RR= Relative risks.

• The panel recommends the use of tricalcium silicate in (95% CI=75.8 to 87.8). MTA and formocresol success rates
vital primary teeth with deep caries lesions treated with were the highest of all pulpotomy types in this time frame
pulpotomy due to pulp exposure during carious dentin and were not significantly different (P=0.15). MTA’s success
removal. (Conditional recommendation, very low-quality rate was 89.6 percent (95% CI=82.5 to 94.0), and formocresol’s
evidence) was 85.0 percent (95% CI=76.3 to 91.0).9 MTA, formocresol,
• The panel recommends against the use of calcium hydroxide and FS success rates were all significantly better than calcium
in vital primary teeth with deep caries lesions treated with hydroxide at 24 months (P=<0.001). Other studies showed
pulpotomy due to pulp exposure during carious dentin NaOCl’s success rate was significantly less than formocresol
removal. (Conditional recommendation, low-quality at 18 months (P=0.01), and other pulpotomy agents’ success
evidence) rates did not differ statistically (FS vs. laser; FS vs. NaOCl; and
calcium hydroxide vs. laser). At 12 months, pulpotomy success
Summary of findings: The systematic review9 suggests that rates for FS vs. laser and MTA vs. tricalcium silicate did not
the overall success rate at 24 months for MTA, formocresol, differ statistically. The summary of findings for pulpotomy
FS, NaOCl, calcium hydroxide, and laser was 82.6 percent interventions is included in Table 6.9
Table 6. SUMMARY OF FINDINGS FOR PULPOTOMY STUDIES
Outcome Illustrative comparative Relative effect (95% CI) Number of Quality of the
comparisons risks (95% CI) participants evidence (GRADE)
1. FC vs. MTA overall FC success= 85.6% RR 1.04 (0.98 to 1.10) favoring 8 studies High
success 24 mos. (76.9 to 91.4) MTA P=0.17 with 455
MTA success= 89.6% NNT= Not significant pulpotomies
(82.5 to 94.0)
FC vs. MTA Comments: At 24 months, the eight studies20,21,23,24,25,26,27,28 involved 214 FC and 241 MTA pulpotomies. At the start of these multi-arm
studies, there were 450 children with 810 teeth.
2. FC vs. FS overall FC success= 87.1% RR 1.02 (0.93 to 1.13) favoring 4 studies Moderate
success 24 mos. (78.2 to 92.7) FC P=0.65 with 216 teeth
FS success= 84.8% NNT= Not significant
(76.2 to 90.6)
FC vs. FS Comments: At 24 months, the four studies20,21,22,25 involved 112 FC and 104 FS pulpotomies. At the start of these multi-arm studies,
there were 232 children with 508 teeth.
3. FC vs. CH overall FC success= 79.0% RR 1.76 (1.40 to 2.23) favoring 4 studies Moderate
success 24 mos. (57.7 to 91.2) FC P=<0.001 with 212 teeth
CH success= 41.4% NNT (significant)= 3. On doing three
(26.5 to 58.1) pulpotomies, one failure would be prevented
if FC was used instead of calcium hydroxide.
FC vs. CH Comments: At 24 months, the four studies22,23,25,31 involved 111 FC and 101 CH pulpotomies. At the start of these multi-arm studies,
4. MTA vs. CH overall MTA success= 89.0% RR 1.96 (1.52 to 2.53) favoring 3 studies Moderate
success 24 mos. (59.6 to 97.8) MTA by 96% P=<0.001 with 190 teeth
CH success= 46.0% NNT (significant)= 3. On doing three
if MTA was used instead of calcium
hydroxide.
MTA vs. CH Comments: At 24 months, the three studies23,25,29 involved 116 MTA and 74 CH pulpotomies. At the start of these multi-arm
studies, there were 114 children with 264 teeth.
5. FS vs. CH overall FS success= 82.1% RR 1.57 (1.19 to 2.06) favoring 2 studies Low
success 24 mos. (68.2 to 90.7) FS by 57% P=<0.001 with 118 teeth
CH success= 52.8% NNT (significant)= 4. On doing four
if FS was used instead of calcium hydroxide.
FS vs. CH Comments: At 24 months, the two studies22,25 involved 65 FS and 53 CH pulpotomies. At the start of these multi-arm studies, there
were 118 children with 120 teeth.

Table 6. CONTINUED
Outcome comparisons Illustrative comparative Relative effect (95% CI) Number of Quality of the
risks (95% CI) participants evidence (GRADE)
6. MTA vs. FS overall MTA success= 92.2% RR 1.11 (0.99 to 1.26) favoring 4 studies Moderate
success 24 mos. (70.7 to 98.3) MTA P=0.06 with 207 teeth
FS success= 79.3% NNT (significant)= 9. On doing nine
(68.0 to 87.4 pulpotomies, one failure would be
if prevented MTA was used instead
of calcium hydroxide.
MTA vs. FS Comments: At 24 months, the four studies20,21,25,30 involved 107 MTA and 100 FS pulpotomies. At the start of these multi-arm studies,
7. FC vs. NaOCl overall FC success= 98.1% RR 1.20 (1.04 to 1.40) favoring 2 studies Low
success 18 mos. (97.6 to 99.7) FC P=0.01 with 91 teeth
NaOCl success= 82.9% NNT (significant)= 6. On doing six
(68.3 to 91.6) pulpotomies, one failure would be
prevented if FC was used instead
of calcium hydroxide.
FC vs. NaOCl Comments: At 18 months, the two studies21,32 involved 50 FC and 41 NaOCl pulpotomies. At the start of these multi-arm studies,
8. FC vs. Laser overall FC success= 94.4% RR 1.14 (0.91 to 1.43) favoring 2 studies Moderate
success 18 mos. (85.3 to 98.0) FC P=0.27 with126 teeth
Laser success= 83.5% NNT= 8 not significant
(63.0 to 93.8)
FC vs. Laser Comments: At 18 months, the two studies22,33 involved 64 FC and 62 laser pulpotomies. At the start of these multi-arm studies, there
was an unknown number of children with 180 teeth.
9. FS vs. NaOCl overall FS success= 89.2% RR 0.99 (0.85 to 1.16) favoring 2 studies Low
success 18 mos. (65.6 to 97.3) neither pulpotomy P=0.88 with 80 teeth
NaOCl success= 92.4% NNT= Not significant
(79.0 to 97.5)
FS vs. NaOCl Comments: At 18 months, the two studies21,32 involved 40 FS and 40 NaOCl pulpotomies. At the start of these multi-arm studies,
10. CH vs. Laser overall CH success= 74.0% RR 1.07 (0.91 to 1.25) favoring 2 studies Low
success 18 mos. (40.8 to 92.1) laser P= 0.41 with 116 teeth
Laser success= 83.5% NNT= Not Significant
(63.0 to 93.8)
CH vs. Laser Comments: At 18 months, the two studies22,33 involved 54 CH and 62 laser pulpotomies. At the start of these multi-arm studies, there were
184 children with 300 teeth.
11. FS vs. Laser overall FS success= 81.9% RR 1.06 (0.94 to 1.19) favoring 2 studies Moderate
success 12 mos. (71.9 to 88.8) laser P=0.34 with 177 teeth
Laser success= 86.1% NNT= Not Significant
(56.8 to 96.7)
FS vs. Laser Comments: At 12 months the two studies22,34 involved 90 FS and 87 laser pulpotomies. At the start of these multi-arm studies, there were
161 children with 320 teeth.
12. MTA vs. Tricalcium MTA success= 94.7% RR 1.01 (0.94 to 1.09) favoring 2 studies Low
silicate overall success (84.8 to 98.3) MTA P=0.83 with 116 teeth
12 mos. Tricalcium silicate success= 95.2% NNT= Not Significant
(86.2 to 98.4)
MTA vs. Tricalcium Silicate Comments: At 12 months the two studies35,36 involved 65 MTA and 63 Tricalcium silicate pulpotomies. At the start of
these multi-arm studies, there were 126 children with 144 teeth.
CI=Confidence interval; CH= Calcium hydroxide; FC= Formocresol; FS= Ferric sulfate; MTA= Mineral trioxide aggregate; NaOCl= Sodium hypochlorite;
NNT= Number needed to treat; RR= Relative risks.

Comparison 4.1. Formocresol vs. MTA pulpotomy (24- one failure could be prevented if formocresol was used instead
months). The systematic review9 evaluated eight studies20,21,23-28 of NaOCl. The quality of the evidence for this outcome at
comparing formocresol to MTA with a follow-up of 24 months, 18 months was moderate due to small sample sizes.
and the meta-analysis favored neither type of pulpotomy med- Comparison 4.8. Comparison 4.8. Formocresol vs. laser
icament (RR 1.04, 95% CI=0.98 to 1.11) (P=0.15). The quality pulpotomy (18-months). The systematic review9 evaluated two
of the evidence for this outcome at 24 months was assessed to studies22,33 comparing formocresol to laser, and the meta-analysis
be high. favored neither type of pulpotomy technique (RR 1.14, 95%
Comparison 4.2. Formocresol vs. FS pulpotomy (24- CI=0.91 to 1.43) (P=0.27). The quality of the evidence for the
months). The systematic review9 evaluated four studies20-22,25 outcomes of these agent comparisons at 18 months was low
comparing formocresol to FS with a follow-up of 24 months, due to small sample sizes.
and the meta-analysis favored neither type of pulpotomy medi- Comparison 4.9. Comparison 4.9. FS vs. NaOCl pulpo-
cament (RR .02, 95% CI=0.93 to 1.13) (P=0.65). The quality tomy (18-months). The systematic review 9 evaluated two
of the evidence for this outcome at 24 months was moderate studies 21,32 comparing FS to NaOCl, and the meta-analysis
due to small sample sizes. favored neither type of pulpotomy medicament (RR 0.99, 95%
Comparison 4.3. Formocresol vs. calcium hydroxide pulp- CI=0.85 to 1.16) (P=0.88). The quality of the evidence for the
otomy (CH) (24-months). The systematic review9 evaluated four outcomes of these agent comparisons at 18 months was low due
studies22,23,25,31 comparing formocresol to CH with a follow-up to small sample sizes.
of 24 months, and the meta-analysis indicated that formocresol Comparison 4.10. CH vs. laser pulpotomy (18-months).
was significantly better than CH (RR 1.76, 95% CI=1.40 to The systematic review9 evaluated two studies22,33 comparing CH
2.23) (P<0.001). In terms of numbers needed to treat (NNT), to laser, and the meta-analysis favored neither type of pulpotomy
on doing three pulpotomies, one failure would be prevented if technique (RR 1.07, 95% CI=0.91 to 1.25) (P=0.41). The quality
formocresol was used instead of CH. The quality of the evidence of the evidence for the outcomes of these agent comparisons
for this outcome at 24 months was moderate due to small at 18 months was low due to small sample sizes.
sample sizes. Comparison 4.11. FS vs. laser pulpotomy (12-months).
Comparison 4.4. MTA vs. CH pulpotomy (24-months). The systematic review9 evaluated two studies22,34 comparing FS
The systematic review9 evaluated three studies23,25,29 comparing to laser, and the meta-analysis favored neither type of pulp-
MTA to CH with a follow-up of 24 months, and the meta- otomy technique (RR 1.06, 95% CI=0.94 to 1.19) (P=0.34).
analysis indicated that MTA was significantly better than CH The quality of the evidence for this outcome at 12 months
(RR 1.96, 95% CI=1.52 to 2.53) (P<0.0001). In terms of was moderate due to small sample sizes.
NNT, on doing three pulpotomies, one failure could be pre- Comparison 4.12. MTA vs. tricalcium silicate pulpotomy
vented if MTA was used instead of CH. The quality of the (12-months). The systematic review9 evaluated two studies35,36
evidence for this outcome at 24 months was moderate due comparing MTA to tricalcium silicate, and the meta-analysis
to small sample sizes. favored neither type of pulpotomy medicament (RR 1.01,
Comparison 4.5. FS vs. CH pulpotomy (24-months). 95% CI=0.94 to 1.09) (P=0.83). The quality of the evidence
The systematic review 9 evaluated two studies 22,25 comparing for this outcome at 12 months was very low.
FS to CH with a follow-up of 24 months, and the meta-analysis
indicated that FS was significantly better than CH. (RR 1.57, Remarks: The head-to-head analysis of all pulpotomy
95% CI=1.19 to 2.06) (P<0.001). In terms of NNT, on doing comparisons presented a challenge in assessing the evidence.
four pulpotomies, one failure could be prevented if FS was The validity of the indirect comparison rests on similarity
used instead of CH. The quality of the evidence for this outcome assumption that the study designs (Population, intervention,
at 24 months was low due to very small sample sizes. and outcomes) and the methodological quality are not suffi-
Comparison 4.6. MTA vs. FS pulpotomy (24-months). ciently different to result in different effects.37 As this assump-
The systematic review9 evaluated four studies20,21,25,30 comparing tion is always in some doubt, indirect comparisons always
MTA to FS with a follow-up of 24 months, with the meta- warrant rating down by one level in quality of evidence.37 The
analysis nearing significance (P=0.06) favoring MTA (RR 1.13, panel recognized that the findings are of high clinical relevance
95% CI=1.00 to 1.29). In terms of NNT, on doing nine pulp- and agreed that it will be of value to produce separate recom-
otomies, one failure could be prevented if MTA was used mendation statements for various pulpotomy medicaments/
instead of FS. The quality of the evidence for this outcome at techniques, even though the quality of evidence had to be
24 months was moderate due to small sample sizes. downgraded. Therefore, for recommendations on pulpotomy
Comparison 4.7. Formocresol vs. NaOCl pulpotomy medicaments and techniques, the panel decided to downgrade
(18-months). The systematic review9 evaluated two studies21,32 the quality of evidence by one level (from the highest level
comparing formocresol to NaOCl with a maximum follow-up recorded for that intervention), owing to the indirect compari-
of 18 months, and the meta-analysis indicated that formocresol sons among various interventions.
was significantly better than NaOCl (RR 1.20, 95% CI=1.04 The panel decided on a recommendation against the use of
to 1.40) (P=0.01). In terms of NNT, on doing six pulpotomies, CH pulpotomy, because the data consistently showed inferior

success for CH pulpotomy. The strength of evidence was values and preferences. Clinicians should give greater care to
conditional, since the quality of evidence was downgraded from consider individual patient factors where the guideline offers
moderate to low to account for indirect comparisons. conditional recommendation.
Research considerations. The panel recognized that to pro- The use of rubber dam is universally accepted as a gold
duce recommendations supported with higher quality evidence, standard for pulp therapies. Since it may be of ethical concern to
there is a need for well-designed clinical trials with multiple design studies with a control group treated without using rubber
arms allowing simultaneous comparisons of more than two dam isolation, there is limited research evaluating benefits of
medicaments or techniques. rubber dam use on primary teeth. However, the panel agreed
Practice implications. The indications, objectives, and type that it is critical to use rubber dam in order to maintain the
of pulpal therapy depend on whether the pulp is vital or non- highest standard of care and to ensure patient safety.41
vital, which is based on the clinical diagnosis of normal pulp It is also important that clinicians select the best post-
(symptom free and normally responsive to vitality testing), re- operative restoration using their clinical expertise and individual
versible pulpitis (pulp is capable of healing), symptomatic or patient preferences. Either intra-coronal restoration or a stainless
asymptomatic irreversible pulpitis (vital inflamed pulp is in- steel crown (SSC) may be adequate to achieve a good marginal
capable of healing), or necrotic pulp.2 In order to replicate the seal for single surface (occlusal) restorations on a primary tooth
recorded vital pulp therapy success rates, proper case selection, with a life span of two years or less; whereas for multi-surface
accurate diagnosis, and utilization of evidence-based technique restorations, stainless steel crowns are the treatment of choice.2,42
are of key importance.
Indirect pulp treatment is a procedure that leaves the Potential adverse effects
deepest caries adjacent to the pulp undisturbed in an effort to Summary of findings: There have been concerns regarding tox-
avoid a pulp exposure. This caries-affected dentin is covered icity related to formocresol and discoloration related to MTA,
with a biocompatible material to produce a biological seal.2,7 and more recently about the nontuberculosis mycobacterial
Direct pulp cap is a technique in which the pulp is covered infection linked to pulpotomy procedures.
with a biocompatible material when caries excavation causes a Formocresol: The panel did not find any reports on toxicity
pin-point pulp exposure.9 Past reports of DPC in primary teeth related to use of formocresol for vital pulp therapies in children.
have shown limited success;16,38 therefore, DPC has had limited Milnes42 reviewed the available evidence on formocresol and
acceptance as a technique for management of carious pulp ex- concluded that when used judiciously for pulpotomy procedure,
posures in the primary dentition. it is unlikely to be genotoxic, immunotoxic, or carcinogenic in
Pulpotomy is a procedure used when the excavation of children. The panel did not find sufficient evidence on adverse
carious dentin in primary teeth produces a pulp exposure. In events that could influence the quality of evidence.
this technique, the entire coronal pulp is removed, hemostasis MTA: The panel found reports of unintended grayish dis-
of the radicular pulp is achieved, and the remaining radicular coloration of teeth treated with MTA (gray and white) pulp-
pulp is treated with one of several different medicaments.3,4,7 otomy. 44-48 One study reported that 94 percent of teeth that
Published studies of this procedure have been reported since the received white MTA pulpotomy and composite restoration turned
early 1900’s,39 and pulpotomy currently is the most frequently gray, suggesting it was not an esthetic alternative to SSC.45 The
used vital pulp therapy technique for deep dental caries lesions discoloration, however, had no influence on the success of vital
in primary teeth.40 pulp therapy. The panel, therefore, did not reduce the quality
AAPD has published this current guideline on vital pulp of evidence owing to the discoloration-related adverse effect of
therapy in primary teeth to provide evidence-based recommend- MTA. Clinicians should be aware of the possibility of coronal
ations on vital pulp therapies in primary teeth with deep caries discoloration with MTA, especially while restoring a tooth with
lesions. In view of the similar success of all three vital pulp composite for esthetic considerations, and make decisions based
therapies, the panel suggests clinicians take the most biological/ on individual preferences. The panel did not find sufficient
conservative approach, which considers caries-affected dentin evidence on adverse events that could influence the quality of
removal, pulp exposures (if any), reported adverse effects, and evidence.
individual preferences. Based on the recommendations, IPT, Nontuberculosis mycobacterial infection: The U.S. Department
DPC, and pulpotomy may all be viable options for treatment of of Health and Human Services (USDHHS)/Centers for Disease
primary teeth with deep caries lesions. Overall, the panel found Control and Prevention (CDC) published a report on Myco-
moderate quality evidence supporting IPT, MTA pulpotomy, bacterium abscessus (M. abscessus) infections among patients
and formocresol pulpotomy. For all other interventions, the treated with pulpotomies.49 The report identified the cause of
quality of evidence was low to very low. The success of IPT and outbreak to be the contaminated water used during pulpo-
DPC was found to be independent of the choice of medicament tomies, which introduced M. abscessus into the pulp chamber
used. For pulpotomy, the panel found higher evidence supporting of the tooth. It was reported that out of 1,386 pulpotomies
use of MTA and formocresol and evidence against the performed since January 2014, as of January 2016, a total of 20
use of CH. Treatment choices should be made based on patients were identified with confirmed or probable M. abscessus
the scientific evidence presented, clinical expertise, and patients’ infections, resulting in a prevalence rate of one percent. All

patients (median age seven years) were severely ill and required Cost-effectiveness of recommendation. Cost-effectiveness
at least one hospitalization (median hospital stay seven days; of a treatment is based on initial and possible retreatment costs.56
range: one-17 days); 17 patients required surgical excision, and 10 Such a cost-analysis for therapies with proven health benefits
received outpatient intravenous antibiotics. As of April 5, 2016, and minimal adverse effects is an important consideration for
no deaths had resulted from infection.49 Since M. abscessus is clinicians, patients, and third-party payors.56 This is especially
ubiquitous in the environment, it poses a contamination risk. important when different procedures with similar outcomes are
To prevent infections associated with waterlines, dental practices available to treat a specific condition like in the case of vital pulp
should monitor water quality, disinfect waterlines as per manu- therapies. A research brief covering claims data for all children
facturer’s instructions, use point-of-use water filters, and eliminate with private dental insurance lists vital pulpotomy, in primary
dead ends in plumbing where stagnant water can enable biofilm or permanent teeth, as one of top 25 most common procedures
formation. 49 The panel did not find sufficient evidence on performed in children with private dental benefits.57 For ages
adverse events that could influence the quality of evidence. one through six years, the spending is estimated to be $257,
Remarks: The panel did not find sufficient evidence on ad- ranging from $160 for children in the lowest quartile of spend-
verse events related to medicaments used for IPT, DPC, and ing to $996 among children in the highest quartile of spend-
pulpotomy that could influence the quality of evidence. However, ing. 57 Considering the number of pulp therapies performed
the panel recognizes that there may still be parental concerns on a population level, cost-effective treatment is a public health
regarding formocresol toxicity and discolorations associated issue. However, very limited data exist on cost-effectiveness
with MTA and recommends that the clinicians should explain of various pulp therapies in the primary dentition. The most
the evidence to parents and make decisions based on individual expensive pulp treatments and modalities with regards to initial
preferences. The panel encourages providers to closely monitor costs are MTA and laser.56,58 Interestingly, a German study using
any updates from the CDC on M. abscessus infection related to the Markov model followed the first permanent molar with vital
pulpotomy procedures for its future implications and possible asymptomatic exposed pulp treated with DPC using MTA or
impact on the evidence. CH over the lifetime of a 20 year old patient and reported that
MTA was more cost-effective than calcium hydroxide despite
Guideline implementation higher initial treatment costs because expensive retreatments were
This guideline, AAPD’s first evidence-based guideline on pulp avoided.56
therapy, is published in both the journal, Pediatric Dentistry, MTA is a suitable medicament for pulpotomy in primary
and the AAPD’s Reference Manual. By meeting the standards of teeth. The main reason for its underutilization has been its
the Institute of Medicine regarding the production of clinical higher cost.58,59 The price of MTA is particularly elevated due to
practice guidelines, these recommendations will be submitted the recommendation to use each package for one patient only.
to the National Guidelines Clearinghouse (NGC), a database of However, new products marketed in a sealed desiccant-lined
evidence-based clinical practice guidelines and related documents bottle quote a shelf life of three years, allowing use for multiple
maintained as a public resource by the Agency for Healthcare treatments. This has lowered the price to be competitive with
Research and Quality (AHRQ) of the USDHHS. Inclusion in other alternative materials.60
the NGC guarantees the guidelines will be accessible and dis- Third-party reimbursement is another cost issue that may
seminated to private and public payors, policy makers, and the unintentionally increase utilization of a specific procedure over
public. Additionally, AAPD members will be notified of the others. Pulpotomies are a widely performed procedure57 and
new guidelines via social media, newsletters, and presentations. are reimbursed by both private and federally funded insurance
The guidelines are available as an open access publication on the companies. Alternatively, IPT with an overall success rate of 94.4
AAPD’s website. Patient education materials are being developed percent, is often bundled as part of the restoration and, therefore,
and will be offered in the AAPD’s online bookstore. not adequately reimbursed or not reimbursed at all. Reimburse-
Practitioners seeking additional support implementing these ment of more conservative, biological approaches of pulp therapy,
guidelines are referred to the following resources: such as IPT, will allow clinicians to make conservative choices
– Treatment of Deep Caries, Vital Pulp Exposure, and Pulp- based exclusively on efficacy and effectiveness of the specific
less Teeth, Chapter 13, McDonald and Avery’s Dentistry procedures.61
for the Child and Adolescent, 10th edition.50 Cost of pulp treatment may be contained by use of effec-
– Pulp Therapy for the Primary Dentition, Chapter 22, Pedi- tive medicaments as determined by evidence-based research and
atric Dentistry Infancy through Adolescence, 5th edition.51 detailed in this guideline, but the only way to reduce costs overall
– Pediatric Endodontics, Chapter 26, Cohen’s Pathways of is to establish dental homes for every child and implement pri-
the Pulp, 11th edition.52 mary prevention by the child’s parents or caregiver. Primary
– Endodontics: Colleagues for Excellence. 53 www.aae.org/ prevention must start early if treatment costs are to be reduced
colleagues. and oral health maintained.
– Preserving Pulp Vitality, Chapter 4, The Principles of
Endodontics.54 Recommendation adherence criteria
– Pediatric Endodontics: Current Concepts in Pulp Therapy Guidelines are used by insurers, patients, and health care prac-
for Primary and Young Permanent Teeth.55 titioners to determine quality of care. Adherence to guideline

recommendations is measured, because it is believed following References

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Appendix
®
PubMed /MEDLINE—date limit 01/2017 Search #5. 7589370 results
(randomized controlled trial[pt] OR controlled clinical trial[pt]
Search #1. 3607 results OR randomized[tiab] OR randomised[tiab] OR randomization
(pulp therap* OR pulpotom* OR pulp cap* OR “Dental [tiab] OR randomisation[tiab] OR placebo [tiab] OR drug
Pulp Capping”[MeSH terms] OR “Pulpotomy”[MeSH terms]) therapy[sh] OR randomly[tiab] OR trial [tiab] OR groups[tiab]
OR clinical trial[pt] OR “clinical trial”[tw] OR “clinical trials”
Search #2. 23275 results [tw] OR “evaluation studies” [publication type] OR “evaluation
(“Root Canal Therapy”[Mesh] OR “Root Canal Preparation”[Mesh] studies as topic” [MeSH terms] OR “evaluation study”[tw]
OR “Root Canal Obturation”[Mesh] OR “Root Canal Filling OR evaluation studies [tw] OR “intervention studies”[MeSH
Materials”[Mesh] OR “Calcibiotic Root Canal Sealer”[Supple- terms] OR “intervention study”[tw] OR “intervention studies”
mentary Concept] OR “Next root canal sealant”[Supplementary [tw] OR “cohort studies”[MeSH terms] OR cohort[tw] OR
Concept] OR “calcium sulfate, zinc oxide, vinyl acetate, zinc “longitudinal studies”[MeSH terms] OR “longitudinal”[tw]
phosphate root canal filling”[Supplementary Concept] OR OR longitudinally[tw] OR “prospective” [tw] OR prospectively
“QMix root canal irrigant”[Supplementary Concept] OR [tw] OR “follow up”[tw] OR “comparative study”[publication
“Root Canal Irrigants”[Mesh]) type] OR “comparative study”[tw] OR systematic[subset] OR
“meta-analysis” [publication type] OR “meta-analysis as topic”
Search #3. 3570082 results [MeSH terms] OR “meta-analysis”[tw] OR “meta-analyses”[tw])
(Infant[MeSH] OR infant * OR infancy OR newborn * OR baby
* OR babies OR neonat * OR preterm * OR premature * OR Search #6. 1906 results
postmature * OR Child[MeSH] OR child * OR schoolchild * OR (#1 OR #2) AND #3 AND #5
school age * OR preschool * OR Kid OR kids OR toddler * OR
Adolescent[MeSH] OR adolesc * OR teen * OR Boy * OR girl * Search #7. 890576 results
OR Minors[MeSH] OR minors * OR Puberty[MeSH] OR (“Economics”[Mesh] OR “Cost of Illness”[Mesh] OR “Cost
puberty * OR pubescent * OR prepubescent * OR Pediatrics Savings”[Mesh] OR “Cost Control”[Mesh] OR “Cost-Benefit
[MeSH] OR paediatric * OR paediatric * OR paediatric * OR Analysis”[Mesh] OR “Health Care Costs”[Mesh] OR “Direct
Schools [MeSH] OR nursery school * OR kinderman * OR pri- Service Costs”[Mesh] OR “economics”[Sub-heading] OR cost)
mary school * OR secondary school * OR elementary school * OR
high school * OR high school *) Search #8. 78 results
(#1 OR #2) AND #3 AND #7
Search #4. 144 results
(#1 OR #2) AND #3 AND PubMed systematic review filter
applied

CLINICAL PRACTICE GUIDELINES: NON-VITAL PULP THERAPIES
Use of Non-Vital Pulp Therapies in Primary Teeth

Developed by
How to Cite: Coll JA, Dhar V, Vargas K, et al. Use of non-vital pulp
therapies in primary teeth. Pediatr Dent 2020;42(5):337-49.
Issued
2020
Abstract
Purpose: To present an evidence-based guideline for non-vital pulp therapies due to deep caries or trauma in primary teeth.
Methods: The authors, working with the American Academy of Pediatric Dentistry, conducted a systematic review/meta-analysis for studies on non-
vital primary teeth resulting from trauma or caries and used the GRADE approach to assess level of certainty of evidence for clinical recommendations.
Results: GRADE was assessed from high to very low. Comparing teeth with/without root resorption, pulpectomy success was better (P<0.001) in
those without preoperative root resorption. Zinc oxide plus iodoform plus calcium hydroxide ([ZO/iodoform/CH]; EndoflasTM) and zinc oxide and
eugenol (ZOE) pulpectomy success did not differ from iodoform (iodoform plus calcium hydroxide; VitapexTM, MetapexTM) (P=0.55) after 18-months;
however, ZO/iodoform/CH and ZOE success rates remained near 90 percent while iodoform was 71 percent or less. Network analysis ratings
showed ZO/iodoform/CH and ZOE better than iodoform. Lesion sterilization tissue repair (LSTR) was better (P<0.001) than pulpectomy in teeth
with preoperative root resorption, but pulpectomy results were better (P=0.09) if roots were intact. Rotary instrumentation of root canals was
significantly faster (P<0.001) than manual, but the quality of fill did not differ (P=0.09) and both had comparable success. Network analysis
ranked ZO/iodoform/CH the best, ZOE second, and iodoform lowest at 18 months. Success rates were not impacted by method of obturation
or root length determination, type of tooth, number of visits, irrigants, smear layer removal, or timing/type of final restoration.
Conclusions: Pulpectomy 18-month success rates supported ZO/iodoform/CH and ZOE pulpectomy over iodoform. LSTR had limited indication for
teeth with resorbed roots and requires close monitoring.
KEYWORDS: CLINICAL RECOMMENDATIONS, GUIDELINE, NON-VITAL PULP, PRIMARY TEETH
Plain language summary X-rays should be taken at least every 12 months to monitor the
Purpose. Untreated decay or trauma can cause the nerve of the treatment. LSTR should be chosen over pulpectomy in teeth
tooth to become irreversibly inflamed, abscessed, or dead. The with root resorption or to retain teeth for up to 12 months that
diagnosis is based on both clinical and radiographic signs and otherwise would be extracted. LSTR treatment should be
symptoms, such as a toothache waking the child in the middle monitored closely in the first year, and after the first year, with
of the night, unprovoked toothache, gum or facial swelling, periodic clinical examinations and X-rays at least every 12 months.
or X-rays showing the tooth has bone loss or root resorption. Pulpectomy and LSTR compared to extraction maintain the
Treatment options for this condition include extraction, root tooth in the arch and eliminate any pain and infection, and the
canal therapy (pulpectomy), or lesion sterilization tissue repair procedure should not cause severe pain after 1-2 days. Root
(LSTR), which involves the placement of antibiotics inside the canal filling materials such as zinc oxide and eugenol (ZOE),
tooth. This manuscript evaluates available treatment options to iodoform, or zinc oxide/iodoform/calcium hydroxide (ZO/
save baby (primary) teeth with dying (irreversibly inflamed), iodoform/CH) are used to fill the root canal space after the
dead (necrotic), or abscessed nerve (pulp) resulting from decay infected pulp is removed. For teeth expected to be in the mouth
or trauma and various factors that impact the treatment’s success for 18 months or longer, zinc oxide/iodoform/CH and ZOE
(e.g., eliminate pain and swelling or pathology on follow-up X-rays). fillers performed better than iodoform fillers. The use of motor-
Methods. The authors, working with the American driven rotary root canal files to instrument the root canals is
Academy of Pediatric Dentistry, systematically reviewed all the faster than hand instrumentation but does not affect treatment
dental literature up to January 2020 on the subject of non-vital success or quality of filling the root canals. Pulpectomy success
(irreversibly inflamed, necrotic) primary tooth pulp treatments. also was not affected by different methods of filling the root
This systematic review used 114 articles published between canals (Lentulo spiral, hand pluggers, or syringe), type of tooth
1972 and 2020 that included randomized and nonrandom- (anterior or posterior), history of trauma, type or timing of final
ized controlled trials as well as studies done in laboratories. The restoration placement, method of root length determination,
authors defined treatment success as the child having no pain smear layer removal, or number of treatment visits to complete
or infection and radiographs showing no signs of pathology. the pulpectomy. Antibiotic mixtures used in LSTR should not
Results. Pulpectomy has a high success rate and can be used include tetracycline since evidence shows that alternate anti-
for the treatment of dead, dying or abscessed primary teeth biotic mixtures performed better than tetracyclines. Extraction
with no evident root resorption. In teeth with no root resorp- is indicated for a nonrestorable tooth whose root(s)and/or
tion, pulpectomy should be chosen over LSTR. Follow-up crown has extensive resorption or destruction. In some cases,

due to parent preferences or other reasons determined by the

GLOSSARY OF TERMS AND ABBREVIATIONS clinician and parent, extraction may be the best option even
95% CI refers to 95 percent confidence interval. if the tooth is restorable. Regarding the quality of the evidence,
AAPD: American Academy of Pediatric Dentistry.
Alternate 3Mix used in LSTR is an antibiotic modification of traditional 3Mix
all of the aforementioned recommendations were based on low
in which tetracycline/minocycline is replaced by another antibiotic such as or very low levels of evidence except two. The recommenda-
clindamycin. tions regarding rotary versus hand instrumentation of root canals
CH is a calcium hydroxide pulpotomy.
DPC (Direct pulp treatment) is done for pinpoint pulp exposures after caries and LSTR for teeth with root resorption had moderate levels of
removal and is sealed with a biocompatable material. evidence. The quality of evidence was not assessed on extractions
FC is a formocresol pulpotomy. of non-restorable teeth. Future trials are needed to further
FS is a ferric sulfate pulpotomy.
GRADE (Grading of Recommendations, Assessment, Development, and evaluate which non-vital treatments are effective with follow-up
Evaluations) provides a framework for specifying health care questions, periods of a minimum of two years.
choosing outcomes of interest and rating their importance, evaluating the
Exceptions to the guideline recommendations. Regarding
available evidence, and bringing together the evidence with considerations of
values and preferences of patients and society to arrive at recommendations. exceptions to the guideline recommendations, treatment plans
I2 statistic is a measurement of inconsistency of the data included in the may have to be altered from the Figure decision tree’s recommen-
meta-analysis.
Indirect pulp treatment leaves the deepest decay to prevent a pulp expo-
dations due to a child’s ability to cooperate, complex medical
sure and seals it with a biocompatable material. conditions, inability to achieve local anesthesia of the tooth,
Iodoform stands for either Vitapex (Neo Dental International Inc, Burnaby, limited oral opening, severe gag reflex, facial swelling, oral pain
British Columbia, Canada) or Metapex (Meta Biomed LTD, Cheongju-si,
Chungcheongbuk-do, South Korea) root canal filler, two identical proprietary with an unclear diagnosis, complications from prior pulp ther-
brands containing an iodoform and calcium hydroxide. apy, or concurrent periodontal problems. Also, parent and patient
Irreversible pulpitis and/or necrosis is a tooth that exhibits any one of the preferences, age, and cost of treatment may alter treatment
following clinical or radiographic findings: 1. history of unprovoked toothache;
2. sinus tract, soft tissue pathology, or gingival swelling not associated with decisions that may not conform to this decision tree or guideline.
periodontal disease; 3. abnormal mobility not associated with exfoliation; 4.
radiographic furcation or periapical radiolucency; 5. external or internal ra-
diographic root resorption. Diagnosis of irreversible pulpitis cannot be based
Scope and purpose
solely on bleeding that cannot be controlled within five minutes. The American Academy of Pediatric Dentistry (AAPD) intends
Lasers are laser pulpotomies. this guideline to aid clinicians in optimizing patient care when
LSTR (lesion sterilization tissue repair) is a procedure for necrotic primary
teeth that usually requires no instrumentation of the root canals or filling
choosing pulp therapies for treating children with non-vital or
of the canals but instead includes placement of an antibiotic mixture in the irreversibly inflamed primary teeth. The pulp diagnosis is based
pulp chamber to disinfect the root canals. on symptoms as well as clinical and radiographic signs. Carious
mm is a millimeter.
MTA is a mineral trioxide aggregate pulpotomy. or traumatized primary teeth diagnosed with irreversible pulpitis
NaOCl (sodium hypochlorite) or common household bleach in one to five percent or necrotic pulp can be treated with non-vital pulp therapies or
concentration or as used in the decision tree is a sodium hypochlorite pulpotomy. extraction. Currently, there are two non-vital pulp therapies for
NNT (number needed to treat) is the average number of teeth needed to
be treated with one pulp treatment method to prevent one failure compared primary teeth: (1) conventional pulpectomy and (2) lesion steril-
to the alternate treatment method. ization tissue repair (LSTR). For this guideline, the overall
Nonrestorable primary tooth is where the root(s) and or crown has exten-
(combined clinical and radiographic) success of pulpectomy and
sive resorption or destruction from caries or trauma or the tooth has a very
poor prognosis and is not considered a candidate for non-vital pulp therapy. LSTR was evaluated. The influence of various factors, such as
Normal pulp is a tooth without reversible or irreversible pulpitis. the number of visits, root length determination method, instru-
NRS is a nonrandomized observational study, and NRSs is the plural.
Pulpectomy is a root canal procedure for primary teeth with irreversible
mentation technique, irrigation, obturation (quality, techniques,
pulpitis or necrotic pulp resulting from caries or trauma in which the root and materials), and removal of the smear layer were evaluated
canals are instrumented with files, irrigated, and filled with a resorbable material. for the overall success of conventional pulpectomy, which was
Pulpotomy is for pulp exposures after caries removal and the entire coronal
pulp is removed and treated with various techiques or medicaments. also compared to LSTR in primary teeth with and without
RCT is a randomized clinical trial, and RCTs is the plural. preoperative root resorption. In addition, reported adverse
Reversible pulpitis is the pulpal diagnosis for a tooth without signs or events such as pain were reviewed for this guideline.
symptoms of irreversible pulpitis but that has provoked pain from eating for
a short duration ( 5-10 minutes). The current recommendation supersedes the section on
ROB (risk of bias) is an assessment of any deviations in the estimate of the “Non-vital pulp treatment for primary teeth diagnosed with
intervention’s results.
irreversible or necrotic pulp” in the AAPD best practices on pulp
SR is the AAPD’s systematic review on non-vital pulp therapies.1
SSC is a stainless steel crown, and SSCs is the plural. therapy for primary and immature permanent teeth2; however,
Success in this guideline refers to the overall success of teeth that show it does not apply to pulp therapy for immature permanent
both clinical and radiographic success simultaneously after pulp treatment.
The AAPD Workgroup (WG) consisted of seven pediatric dentists nominated
teeth or pulp therapy for primary teeth with traumatic injuries.
by the AAPD to perform a systematic review. Clinical questions addressed. The AAPD Workgroup (WG)
Traditional 3Mix is typically a mixture of three antibiotics (minocycline, used the Population, Intervention, Control, and Outcome
metronidazole, and ciprofloxacin) blended in a propylene glycol base and used
in LSTR treatment. (PICO) formulation to develop the following clinical questions
ZO/iodoform/CH (zinc oxide/iodoform/calcium hydroxide) root canal filler that will aid clinicians in the use of non-vital pulp therapies
stands for Endoflas (Sanlor Laboratories, Miami, Fla., USA), which is a in primary teeth:
proprietary brand containing iodoform, zinc oxide, and calcium hydroxide.
ZOE root canal filler stands for a mixture of zinc oxide powder and the 1. In primary teeth, how do we diagnose irreversible
liquid eugenol. pulpitis/pulp necrosis?

2. In non-vital primary teeth, when should a clinician c) In primary teeth treated with pulpectomy, does the
choose extraction over non-vital pulp therapy? instrumentation (hand instruments versus rotary)
3. In non-vital primary teeth, does pulpectomy have technique influence time of treatment, quality of fill,
better long-term success in teeth with or without root and success?
resorption? d) In primary teeth treated with pulpectomy, does
a) In primary teeth with no root resorption needing the removal of the smear layer influence success?
non-vital pulp therapy, how does the success of e) In primary teeth treated with pulpectomy, does
LSTR compare to conventional pulpectomy? the choice of irrigants influence success?
b) In primary teeth with significant root resorption f ) In primary teeth treated with pulpectomy, does
(external greater than one millimeter (mm) and/or the choice of obturation material influence success?
internal) needing non-vital pulp therapy, how does g) In primary teeth treated with non-vital pulp therapy,
the success of LSTR compare to conventional does the timing and/or type of final restoration
pulpectomy? influence success?
4. In primary teeth treated with pulpectomy, what factors h) In primary teeth treated with pulpectomy, does
influence success? the obturation technique (syringe, Lentulo, hand
a) In primary teeth treated with pulpectomy, does the pluggers) influence the quality of fill and success?
number of treatment visits influence success? i) In primary teeth treated with pulpectomy, does
b) In primary teeth treated with pulpectomy, does tooth type (incisor, primary first molar, primary
the method of root length determination influence second molar) influence success?
success? j) In teeth that are necrotic as a result of trauma, is
pulpectomy successful?
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Figure. Guideline decision tree recommendations. Abbreviations in figure, see Glossary of Terms and Abbreviations.

5. In primary teeth treated with pulpectomy, does the type was updated by one of the authors. Title, abstract, and full-text
of isolation technique influence success? review of studies was done in duplicate independently by some
6. In primary teeth treated with LSTR, what factors WG members. They extracted the data and performed the risk
influence success? of bias assessment (ROB) and meta-analyses.
a) When doing LSTR, how does traditional 3Mix Assessment of the evidence. This guideline is based on
(with tetracycline) compare to alternate 3Mix the SR 1 that assessed the quality of the evidence using the
(without tetracycline)? Grades of Recommendation Assessment, Development, and
b) When doing LSTR, should the root canals be filed Evaluation (GRADE)3-5 approach.
or broached? Weaknesses of this guideline are inherent to the limitations
7. What are the adverse events associated with non-vital found in the SR upon which this guideline is based. Limitations
pulp therapy in primary teeth? include failure to review non-English language studies other
than those in Spanish, Portuguese, and Chinese, and the recom-
Methods mendations are based on combined data from studies of different
The AAPD previously published best practices2 on non-vital risks of bias.
pulp therapy entitled “Pulp Therapy for Primary and Immature Formulation of the recommendations. The WG evaluated
Permanent Teeth,” which was last revised in 2019. Evidence from and voted on the level of certainty of the evidence using the
a systematic review and meta-analysis of non-vital pulp therapy GRADE approach. The GRADE approach recognizes the
for primary teeth,1 published with this guideline, is the basis for evidence quality and certainty as high, moderate, low, and very
the current guideline’s recommendations. low 4,5 based on serious or very serious issues, including the
Search strategy and evidence inclusion criteria. It was ROB, imprecision, inconsistency, indirectness of evidence, and
decided a priori to use the AAPD’s systematic review (SR) on publication bias. To formulate the recommendations, the WG
non-vital pulp therapies. 1 The WG used multiple literature used an evidence-to-decision framework, including domains
searches in PubMed®/MEDLINE, Embase®, Cochrane Central such as priority of the problem, certainty in the evidence, balance
Register of Controlled Trials, and trial databases to identify between desirable and undesirable consequences, and patients’
randomized controlled trials (RCTs) and systematic reviews values and preferences. The strength of a recommendation was
addressing peripheral issues not covered by the review, such assessed to be either strong or conditional, which presents dif-
as patient preferences and impact of cost. The search strategy ferent implications for patients, clinicians, and policy (Table 1).
For patients Most individuals in this situation would want Most individuals in this situation would want the suggested course of action,
the recommended course of action; only a small but many would not.
proportion would not.
For clinicians Most individuals should receive the recommended Recognize that different choices will be appropriate for different patients and
course of action. Adherence to this recommenda- that you must help each patient arrive at a management decision consistent with
tion according to the guideline could be used as a her or his values and preferences. Decision aids may well be useful in helping
quality criterion or performance indicator. Formal individuals making decisions consistent with their values and preferences.
decision aids are not likely to be needed to help Clinicians should expect to spend more time with patients when working toward
individuals make decisions consistent with their a decision.
values and preferences.
For policymakers The recommendation can be adapted as policy Policymaking will require substantial debates and involvement of many stake-
in most situations, including for the use of holders. Policies are also more likely to vary between regions. Performance
performance indicators. indicators would have to focus on the fact that adequate deliberation about the
management options has taken place.
Quality of evidence
High The American Academy of Pediatric Dentistry Workgroup is very confident that the true effect lies close to that of the estimate of the effect.
Moderate The American Academy of Pediatric Dentistry Workgroup is moderately confident in the effect estimate: The true effect is likely to be
close to the estimate of the effect, but there is a possibility it is substantially different.
Low The American Academy of Pediatric Dentistry Workgroup’s confidence in the effect estimate is limited: The true effect may be
substantially different from the estimate of the effect.
Very low The American Academy of Pediatric Dentistry Workgroup has very little confidence in the effect estimate: The true effect is likely to be
substantially different from the estimate of effect.
Quality of evidence is a continuum; any discrete categorization involves some degree of arbitrariness. Nevertheless, the advantages of simplicity,
transparency, and vividness outweigh these limitations.

The guidelines were formulated via teleconferences, in-person Summary of findings: The clinical signs and symptoms and
meetings, and online forum discussions with members of the radiographic findings suggestive of irreversible pulpitis/pulp
WG. The WG members discussed all recommendations and necrosis in primary teeth were based on the selection criteria
issues surrounding the topic under review, and all significant used by the studies included in the SR.1 Diagnosis of irreversible
topics such as recommendations were voted upon anonymously. pulpitis cannot be based solely on pulpal bleeding that cannot
Understanding the recommendations. These clinical be controlled within five minutes.7
practice guidelines provide recommendations for non-vital Remarks: According to the AAPD best practices for pulp
pulp therapies in primary teeth. GRADE rates the strength of therapy for primary and immature permanent teeth,2 a tooth
a recommendation as either strong or conditional in favor of planned for pulpotomy where the hemorrhage cannot be
or against an intervention. The strength of a recommendation “controlled with a damp cotton pellet applied for several minutes”
presents different implications for patients, clinicians, and exhibits signs of irreversible pulpitis. There is no reference for
policymakers. this statement. A recent study 7 concluded that “controlling
A strong recommendation in favor of the intervention bleeding at the exposure site or canal orifices does not provide
implies the WG is confident that the desired benefits of the an accurate assessment of inflammation at the canal orifice and
intervention outweigh any undesirable effects. A strong recom- may be misleading for diagnosing vital pulp treatment in pri-
mendation against the intervention implies the WG is confi- mary teeth with carious pulp exposure.” Therefore, the inability
dent that the undesired effects of the intervention outweigh any to control pulpal hemorrhage after a few minutes may not
potential benefits. A strong recommendation (for or against) solely be a reliable indicator of irreversible pulpitis.
means that, in most situations, clinicians may want to follow
the WG’s suggested course of action. Question 2. In non-vital primary teeth, when should a clinician
A conditional recommendation in favor indicates that, choose extraction over non-vital pulp therapy?
while there is appreciable uncertainty, the desired effects may Recommendation: The WG did not find any direct evidence
outweigh the undesired effects of the intervention. A conditional to make a recommendation on the criteria to be used by
recommendation against implies that, while there is appreciable clinicians for choosing extraction over non-vital pulp therapy
uncertainly, the undesirable effects probably outweigh the in non-vital primary teeth. It is suggested that, for teeth deemed
potential benefits of the intervention. A conditional recommen- nonrestorable or when the patient has one or more exceptions
dation (for or against) means the WG recognizes that the clinician to the guideline recommendations stated previously in this
may want to follow the suggested course of action while being guideline and Figure, the treatment of choice may be extraction.
cognizant of the various other treatment choices, individual Summary of findings: The AAPD’s SR 1 stated the RCT
patient’s circumstances, preferences, and values. A recommendation articles on pulpectomy and LSTR showed nonrestorable teeth
statement with “must” or “shall” indicates an imperative need were extracted. Teeth were not considered for pulpectomy or
and/or duty is an essential or indispensable item/mandatory; a LSTR if they had an inadequate crown or extensive root structure
recommendation with “should” indicates the recommended need resorption and were not restorable.
and/or duty highly desirable, and a recommendation with “may”
or “could” indicates freedom or liberty to follow a suggested Question 3. In non-vital primary teeth, does pulpectomy
alternative.6 Table 2 shows a summary of the recommendations have better long-term success in teeth with or without root
included in this guideline. resorption?
Recommendation: Evidence suggests that pulpectomy is a
Recommendations viable long-term treatment for non-vital primary teeth without
Question 1. In primary teeth, how do we diagnose irreversible root resorption compared to those with root resorption. There-
pulpitis/pulp necrosis? fore, pulpectomy should be considered for non-vital primary
Recommendation: The WG’s review did not find any direct teeth without preoperative root resorption. (Conditional recom-
evidence to make a recommendation on the criteria to be used mendation, very low quality of evidence—12 months; conditional
by clinicians for diagnosing irreversible pulpitis/pulp necrosis recommendation, very low quality of evidence—24 months.)
in primary teeth. It is suggested that a child’s tooth with one or Summary of findings: Studies on pulpectomy success of 12
more clinical signs or symptoms of unprovoked toothache, months or longer, irrespective of the root canal filler type or
sinus tract or other soft tissue pathology, gingival swelling not method of obturation, were evaluated in the SR1 using a meta-
associated with periodontal disease, abnormal tooth mobility, or analysis comparing teeth with and without root resorption.
radiographically furcation or periapical radiolucency or external Those without root resorption had statistically significant higher
or internal root resorption be diagnosed as having irreversible success (89 percent) compared to those with root resorption (47
pulpitis/pulp necrosis (Figure; see normal/reversible pulpitis percent). The quality of the evidence for this result was very low,
and irreversible pulpitis/necrosis). according to the GRADE at 12 months, due to the very serious
heterogeneity seen in the I2 statistic and very serious indirectness
due to the indirect comparison.

Table 2. SUMMARY OF CLINICAL RECOMMENDATIONS ON NONVITAL PULP THERAPIES IN PRIMARY TEETH*
Clinical question Recommendation Quality of evidence Strength of

1. In primary teeth, how do we diagnose No evidence-based dentistry recommendation

irreversible pulpitis/pulp necrosis?
2. In nonvital primary teeth, when should a No evidence-based dentistry recommendation
clinician choose extraction over nonvital
pulp therapy?
3. In nonvital primary teeth, does pulpec- Pulpectomy is a viable long-term treatment for nonvital teeth Very low Conditional
tomy have better long-term success in without root resorption compared to those with root re- (12 months)
teeth with or without root resorption? sorption. Therefore, pulpectomy should be considered for
nonvital primary teeth without preoperative root resorption. Very low Conditional
(24 months)
a) In primary teeth with no root resorption Pulpectomy success was higher than LSTR for teeth without Low Conditional
needing nonvital pulp therapy, how does the preoperative root resorption, indicating it should be preferred (12 months)
success of LSTR compare to conventional over LSTR in these teeth.
pulpectomy?
b) In primary teeth with significant root re- If the clinician decides not to extract the tooth with significant Moderate Conditional
sorption (external greater than one mm preoperative root resorption, LSTR should be chosen over (12 months)
and/or internal) needing nonvital pulp pulpectomy to save such teeth for up to 12 months and should
therapy, how does the success of LSTR be monitored with periodic clinical exams and radiographs
compare to conventional pulpectomy? at least every 12 months.
4. In primary teeth treated with pulpectomy what factors influence success?

a) In primary treated with pulpectomy, does In primary teeth treated with pulpectomy the overall success Very low Conditional
the number of treatment visits influence after 12 months was not impacted by the number of visits; (12 months)
success? therefore, it is suggested that the clinicians may choose
either one-visit or two-visit pulpectomy based on clinical
expertise and individual circumstances.
b) In primary teeth treated with pulpectomy, Clinicians may choose any of the methods (tactile, Very low Conditional
does the method of root length determina- radiographs, apex locators) based on their clinical expertise
tion influence success? and individual circumstances.
c) In primary teeth treated with pulpectomy, Rotary instrumentation time was significantly shorter than Moderate Conditional
does the instrumentation (hand instru- manual by approximately two minutes, but the two instru-
ments versus rotary) technique influence mentation methods had comparable successes while the
time of treatment, quality of fill, and occurrence of flush fills favored rotary. Considering these
success? findings and the additional resources/training for rotary
over manual instrumentation, clinicians may choose either
method of instrumentation.
d) In primary teeth treated with pulpectomy, No evidence-based dentistry recommendation

does the removal of the smear layer influ-
ence success?
e) In primary teeth treated with pulpec- The choice of irrigants (sodium hypochlorite one to five Very low Conditional
tomy, does the choice of irrigants influence percent, water/saline, or chlorhexidine) had no impact on
success? pulpectomy success. Therefore, the clinician may choose any
of these irrigation solutions based on their clinical expertise
and individual circumstances.
* LSTR=lesion sterilization tissue repair; ZOE=zinc oxide eugenol; ZO/iodoform/CH=zinc oxide, iodoform, and calcium hydroxide.
The 24-month findings were similar to the 12-month without preoperative root resorption. Teeth with resorption had
findings, but there was only one study with root resorption and significantly less success (59 percent) compared to teeth without
one without root resorption. Therefore, a meta-analysis of RCTs resorption (88 percent). The quality of the evidence for this
was not computed. A meta-analysis of pulpectomy studies with result was very low according to GRADE at 24 months, due
24-month follow-up was conducted for combined RCT non- to high ROB and very serious indirectness.
randomized observational study (NRS) success rates in the SR.1
There was a significant difference between the teeth with or

Table 2. CONTINUED*
Clinical question Recommendation Quality of evidence Strength of

f) In primary teeth treated with pulpectomy, The evidence suggests that ZO/iodoform/CH and ZOE may Very low Conditional
does the choice of obturation material be a better choice for pulpectomy success compared to (18 months)
influence success? iodoform at 18 months. The network analysis after 18 months
showed that ZO/iodoform/CH ranked first followed by ZOE
and then iodoform.
g) In primary teeth treated with nonvital The 12-month data showed stainless steel crowns versus fill- Very low Conditional
pulp therapy, does the timing and/or type ings had comparable success unaffected by the timing of
of final restoration influence success? when the final restoration was placed. The limited 24-month
data suggests that the teeth restored with stainless steel
crowns had better success than composites. Therefore, the
clinician may choose the type and timing of restoration
placement based on their clinical preference.
h) In primary teeth treated with pulpectomy, The quality of the fill (flush fill) and pulpectomy success Very low Conditional
does the obturation technique (syringe, using lentulo spirals, hand pluggers, and syringes were not
lentulo, hand pluggers) influence the statistically different. The clinician may choose any of these
quality of fill and success? obturation techniques based on clinical preference.
i) In primary teeth treated with pulpectomy, No evidence-based dentistry recommendation.

does the tooth type (incisor, primary first
molars primary second molars) influence
success?
j) In teeth that are necrotic as a result of No evidence-based dentistry recommendation.

trauma, is pulpectomy successful?
5. In primary teeth treated with pulpectomy, No evidence-based dentistry recommendation.
does the type of isolation technique influ-
ence success?
6. In primary teeth treated with LSTR, what

factors influence success?
a) When doing LSTR, how does traditional Considering the significantly higher success of alternate Very low Conditional
3Mix (with tetracycline) compare to alter- 3Mix and the potential adverse effects of tetracycline in
nate 3Mix (without tetracycline)? children, when doing LSTR clinicians should choose an
alternate 3Mix (without tetracycline) over traditional 3Mix.
b) When doing LSTR, should the root canals When doing LSTR, clinicians may choose whether or not to Very low Conditional
be filed or broached? file/broach the canals since both methods were not signifi-
cantly different in success.
7. What are the adverse events associated with No evidence-based dentistry recommendation.
nonvital pulp therapy in primary teeth?
* LSTR=lesion sterilization tissue repair; ZOE=zinc oxide eugenol; ZO/iodoform/CH=zinc oxide, iodoform, and calcium hydroxide.
Remarks: For longer periods (24 to 60 months) from RCT Summary of findings: For teeth with no external or internal
and NRS articles, pulpectomy success in teeth without pre- root resorption from direct comparison data, LSTR success was
operative root resorption from the SR1 had higher success (84 65 percent compared to 92 percent for pulpectomy success.
to 90 percent) versus teeth with preoperative root resorption For this comparison, the meta-analysis favored pulpectomy,
(59 to 69 percent). although the difference was not statistically different (relative
risk [RR] equals 0.77; 95 percent confidence interval [95% CI]
Question 3a. In primary teeth with no root resorption needing equals 0.56 to 1.05).1 The NNT equals five, which means that
non-vital pulp therapy, how does the success of LSTR compare after 12 months one failure may be prevented for every five
to conventional pulpectomy? teeth using pulpectomy instead of LSTR. The quality of the
Recommendation: Pulpectomy success was higher than evidence for this result was low, according to the GRADE at
LSTR for teeth without preoperative root resorption, indicating 12 months, due to a serious imprecision seen in the sample sizes
it should be preferred over LSTR in these teeth. (Conditional and the serious heterogeneity seen in the I2 statistic (measure-
recommendation, low quality of evidence.) ment of inconsistency of the data included in the meta-analysis).

Question 3b. In primary teeth with significant root resorption and individual circumstances. (Conditional recommendation,
(external greater than one mm and/or internal) needing non- very low quality of evidence.)
vital pulp therapy, how does the success of LSTR compare to Summary of findings: The effect of whether the method
conventional pulpectomy? of root length determination altered success was tested with
Recommendation: If the clinician decides not to extract the meta-analyses in the SR.1 For the studies that used an apex locator,
tooth with significant preoperative root resorption, LSTR the pooled success was 79 percent compared to 86 percent for
should be the choice over pulpectomy to save such teeth for those that used radiographs. The two methods were not signifi-
up to 12 months, but if retained longer should be monitored cantly different (P=0.28). The quality of the evidence for this
with periodic clinical exams and radiographs at least every 12 finding was very low due to the very serious inconsistency in
months after doing LSTR. (Conditional recommendation, the I2 statistic and indirect comparison.
moderate quality of evidence.) Remarks: There was one in vivo study11 of single-rooted
Summary of findings: For teeth with external or internal root primary anterior teeth using an apex locator, radiographs, and
resorption from direct comparison data, the LSTR success rate tactile feel of the apex in the mouth to the actual length of the
was 76 percent compared to the pulpectomy success rate of 47 tooth after it was extracted. This article did not evaluate pulpec-
percent. This included teeth where the canals were filed or not tomy success. Of the 22 teeth without root resorption, the apex
before antibiotic placement for LSTR. The meta-analysis was locator and radiographs mean length deviation from the actual
significant (P=0.001), favoring LSTR1 (RR equals 1.65; 95% mean length of 15 mm was insignificant while the tactile feel
CI equals 1.31 to 2.08). The NNT equals four, meaning one method was one mm significantly shorter in the same teeth. In
failure would be prevented for every four teeth using LSTR 29 teeth with apical root resorption, the mean lengths for tactile
instead of pulpectomy. The quality of the evidence for this result feel, radiographic, and apex locator were 0.1 mm shorter than
was moderate, according to the GRADE at 12 months, due to the actual length. Two clinical NRSs 12,13 used tactile feel for
the serious imprecision seen in the sample sizes. their primary tooth pulpectomies. They had success data that
Remarks: Qualitative data from prospective8,9 studies showed could be computed for 21 months on primary molars (96.6
the combined 24-month LSTR success was 37 percent in percent success; 513 out of 531) and 46 months (93.8 percent;
these studies. The report from Grewal 10 is a 36-month RCT; 485 out of 517).
it found that LSTR treatment adversely affected the permanent
tooth eruption due to interradicular bone loss and, in one case, Question 4c. In primary teeth treated with pulpectomy, does
caused an odontogenic keratocyst. Perhaps LSTR should be the instrumentation (hand instruments versus rotary) technique
used only to save primary molars for up to 12 months to main- influence time of treatment, quality of fill, and success?
tain space and then be monitored periodically. Recommendation: Rotary instrumentation time was signifi-
cantly shorter than manual instrumentation time by approxi-
Question 4. In primary teeth treated with pulpectomy, what mately two minutes, but the two instrumentation methods
factors influence success? had comparable successes while the occurrence of flush fills (a
Question 4a. In primary teeth treated with pulpectomy, does root canal filled to the apex) favored rotary. Considering these
the number of treatment visits influence success? findings and the additional resources/training for rotary over
Recommendation: In primary teeth treated with pulpec- manual instrumentation, clinicians may choose either method
tomy, the overall success after 12 months was not impacted by of instrumentation. (Conditional recommendation, moderate
the number of visits; therefore, it is suggested that clinicians of evidence.)
may choose either a one-visit or two-visit pulpectomy based on Summary of findings: manual versus rotary canal preparation
clinical expertise and individual circumstances. (Conditional time. The meta-analysis comparing rotary to manual canal filing
recommendation, very low quality of evidence.) showed a significant difference favoring rotary filing, which
Summary of findings: The effect of whether one- or two-visit was approximately two minutes faster than manual filing
pulpectomy affected success was tested with meta-analyses in (mean difference [MD] equals -126; 95% CI equals -167 to -85;
the SR. 1 For the one-visit group, the pooled success was 74 P<0.0001). 1 The quality of the evidence for this result was
percent compared to 81 percent for the two-visit group. The high according to the GRADE. Although there was hetero-
difference between the groups was not significantly different. geneity seen in the I 2 statistic, this was only due to how
The quality of the evidence for this finding was very low due to much faster rotary canal preparation was compared to manual
the very serious inconsistency in the I2 statistic and the indirect preparation. Only one clinical study14 compared manual versus
comparison. rotary filing after 24 months, and there was no significant
difference in the two groups’ pulpectomy success. The anti-
Question 4b. In primary teeth treated with pulpectomy, does bacterial observational study by Subramaniam 15 evaluating
the method of root length determination influence success? manual versus rotary canal preparation showed no difference in
Recommendation: Evidence suggests that clinicians may bacterial reduction.
choose any of the root length determination methods (tactile,
radiographs, apex locators) based on their clinical expertise

Manual versus rotary optimum (flush) filling outcome. The Summary of findings: There were three studies in the SR1
meta-analysis favored the use of rotary filing compared to that only used sodium hypochlorite (NaOCl) as the canal
manual root canal filing for achieving a flush apical fill. Although irrigation method. Three other studies used NaOCl and either
there was no statistical difference (P=0.07), the use of rotary saline or distilled water during the canal preparation or as the
filing had 32 percent more flush fills than those using manual final irrigation solution. The effect of whether the type of
filing. 1 The NNT equals six, meaning that, after doing six irrigation altered success was tested with meta-analyses. For the
pulpectomies with manual filing, one more flush fill may studies that used NaOCl, the pooled success was 80 percent
have occurred using rotary compared to manual. The quality versus 81 percent for those that used NaOCl and saline and/
of the evidence for this result was moderate according to or distilled water. The difference between the groups was not
the GRADE due to serious heterogeneity seen in the I2 statistic. significant.1 The quality of the evidence for this result was very
Remarks: Rotary instrumentation required less time and low according to the GRADE due to the serious heterogeneity
involved less dentin removal and more uniform root canal in the I2 and the indirectness of the comparisons.
preparation.16 Since many primary tooth root canals are ribbon- Remarks: The SR 1 investigated irrigation of root canals
shaped and rotary instruments are centered in root canals, rotary using water/saline, NaOCl, and chlorhexidine on pulpectomy
instrumentation may potentially leave behind infected tissue success after 12 months. This data came from a mixture of RCTs
in unclean areas in fins and isthmuses; also, additional hand and NRSs with different pulpectomy fillers and methods. The
instrumentation with copious irrigation may be needed to articles could not be appropriately grouped to conduct direct
remove the remnant tissues.17 The higher cost of a rotary system comparisons of the irrigation methods. This data could only
and the need for training to learn the technique are additional compute overall pulpectomy success using the three irrigation
factors to consider. solutions. The water/saline group evaluated eight studies, which
had a pulpectomy success rate of 81 percent (341 out of 421).
Question 4d. In primary teeth treated with pulpectomy, does The success rate of the pulpectomies from 12 studies in the
the removal of the smear layer influence success? NaOCl group was 89 percent (1,370 out of 1,538). For the
Recommendation: The WG did not find adequate evidence three studies in the chlorhexidine group, the success rate of the
to make a recommendation on the influence of smear layer pulpectomies was 87 percent (162 out of 186).
removal on the success of the pulpectomy. In the SR,1 primary
tooth pulpectomy success did not seem to depend on whether Question 4f. In primary teeth treated with pulpectomy, does
or not the smear layer was removed. Therefore, it is suggested the choice of obturation material influence success?
that the clinician choose either way of managing the smear Recommendation: The evidence suggests that zinc oxide/
layer based on clinical expertise and individual circumstances. iodoform/calcium hydroxide (ZO/iodoform/CH) and zinc
Summary of findings: The effect of smear layer removal oxide eugenol (ZOE) may be a better choices for pulpectomy
in primary teeth was evaluated in two RCTs in the SR.1 They success compared to iodoform at 18 months. (Conditional
could not be evaluated statistically since one was a 24-month recommendation, very low quality of evidence.) The network
study and the other a 36-month study. The 36-month study analysis after 18 months showed that ZO/iodoform/CH ranked
showed, with smear layer removal, a pulpectomy success rate first, ZOE second, and iodoform last.
of 82 percent (14 out of 17) versus 88 percent (15 out of 17) Summary of findings: pulpectomy root canal fillers—ZOE
without smear layer removal, and the 24 months study had versus iodoform pulpectomy success after 18 months. The meta-
similar success rates that also were not statistically different. analysis showed no significant difference between the success
Smear layer removal for pulpectomy in primary teeth does not rates for ZOE (92 percent) and iodoform (71 percent) at 18
seem to alter its success. months. 1 The ZOE success rate was 14 percent better than
Remarks: The smear layer is an accumulation of dentin and iodoform; the NNT equals 12, indicating that, after doing 12
pulpal debris formed on the root canal walls during instrumen- pulpectomies, one failure may have been prevented using ZOE
tation for a pulpectomy by rotary or manual filing. Its removal compared to iodoform. The quality of the evidence for this
possibly allows the root canal filler to adapt better to the canal result was very low, according to the GRADE at 18 months,
walls, but the smear layer may occlude the dentin tubules and due to the very serious heterogeneity in the I2 statistic, high
prevent bacteria and toxin penetration. ROB, and sample size issues.
ZOE versus ZO/iodoform/CH success 18 months. The ZO/
Question 4e. In primary teeth treated with pulpectomy, does iodoform/CH success rate was 93 percent versus 89 percent for
the choice of irrigants influence success? ZOE at 18 months, and the meta-analysis showed no signifi-
Recommendation: The choice of irrigants (sodium hypo- cant difference.1 The quality of the evidence for this result was
chlorite one to five percent, water/saline, or chlorhexidine) had low, according to the GRADE at 18 months, due to the high
no impact on pulpectomy success. Therefore, the clinicians may ROB, serious imprecision seen in the sample sizes in each arm.
choose any of these irrigation solutions based on their clinical ZO/iodoform/CH versus iodoform success 18 months. The
expertise and individual circumstances. (Conditional recommen- ZO/iodoform/CH success rate was 93 percent compared to
dation, very low quality of evidence.) 63 percent for iodoform at 18 months, and the meta-analysis

showed no significant difference.1 The quality of the evidence had better success than composites. Therefore, the clinician
for this result was very low, according to the GRADE at 18 may choose the type and timing of restoration placement based
months, due to the high ROB, serious imprecision seen in the on their clinical preference. (Conditional recommendation,
sample sizes in each arm, and the very serious heterogeneity in very low quality of evidence.)
the I 2 statistic. The nonsignificant NNT equals seven means Summary of findings: type of final restoration. The SR1 found
after 18 months, meaning you may prevent one failure after 15 studies treated teeth with SSCs and five other studies treated
seven pulpectomies using ZO/iodoform/CH instead of teeth with a filling (composite or amalgam). A meta-analysis
iodoform. tested for any 12-month pulpectomy success differences
Remarks: The meta-analysis1 at 18 months showed a signi- between the two groups and found no significant difference.
ficant difference (P<0.001) between the success of ZO/ The quality of the evidence for this result was very low,
iodoform/CH and the Vitapex brand of iodoform (RR equals according to the GRADE, due to the very serious heterogeneity
1.73; 95% CI equals 1.34 to 2.33). The Metapex brand of in the I2 and indirect comparison. The SR1 reported on four
iodoform showed no significant difference in success compared NRSs with 24-month data on the type of restoration and
to ZO/iodoform/CH (RR equals 1.27; 95% CI equals 0.78 success using SSCs and two that used composites. These articles
to 1.12). were a mixture of RCTs and observational studies. They showed
Network analysis: The objective of a network meta-analysis 24-month pulpectomy success for SSC was 90 percent and for
is to combine both the direct and indirect evidence across all composite was 77 percent.
studies. The network meta-analysis also ranks the effectiveness Timing of final restoration. The SR1 found 12 studies that
of the studied interventions. The 18-month network analysis treated the teeth on the same day as the pulpectomy and 10
of pulpectomy filler success ranked ZO/iodoform/CH first, studies that treated the teeth at a later date. For treatment the
ZOE second, and iodoform worst.1 Regarding the cumulative same day, the pulpectomy success after 12 months was 82 per-
probability percentages of rankings, ZO/iodoform/CH and cent compared to 83 percent for placing the restoration at a
ZOE were markedly better than iodoform. From the 18-month later date (one day to one or more weeks later). The difference
direct comparison data, ZO/iodoform/CH or ZOE appeared between the groups was not significant. The quality of the
to maintain an 18-month success rate near or above 90 percent evidence for this result was very low, according to the GRADE,
over time while iodoform success decreased to 71 percent or due to the very serious heterogeneity in the I 2 and indirect
lower. comparison.
ZOE and ZO/iodoform/CH versus calcium hydroxide success
12 and 18 months. Two RCTs compared ZOE pulpectomy Question 4h. In primary teeth treated with pulpectomy, does
success to different CH brands at 12 months. The ZOE success the obturation technique (syringe, Lentulo, hand pluggers)
rate was 99 percent compared to the CH success rate of 74 influence the quality of fill and success?
percent. The meta-analysis showed a nonsignificant difference Recommendation: The quality of the fill (flush fill) and
between the success rates of ZOE (99 percent) and one CH pulpectomy success using Lentulo spirals, hand pluggers, and
brand (74 percent).1 In the SR1 sensitivity analysis, the other syringes were not statistically different. The clinicians may
CH brand meta-analysis result was statistically different choose any of these obturation techniques based on their clin-
(P<0.0001) The NNT equals four, meaning after 12 months one ical preference. (Conditional recommendation, very low quality
failure would be prevented using a ZOE pulpectomy instead of evidence.)
of CH. The quality of the evidence for this result was low, Summary of findings: quality of pulpectomy fill. The SR 1
according to the GRADE at 12 months, due to the high ROB used a forest plot and compared the pulpectomy data on flush
and serious imprecision in the sample sizes. fills (a root canal filled to the apex) from nine studies using
The SR 1 found only one RCT at 18 months comparing Lentulo spirals, five using hand pluggers, and nine using
ZOE to CH. The ZOE success rate was 100 percent (40 out syringes. Using a Lentulo spiral resulted in 63 percent flush fills
of 40) compared to the CH success of 85 percent (34 out of versus 48 percent with a hand plugger and 62 percent with a
40). The same RCT had different arms of CH compared to ZO/ syringe. There was no significant difference for the three
iodoform/CH success. There was no valid comparison using methods of obturation achieving pulpectomy flush fills. This
these pulpectomy success rates at 12 or 18 months; therefore, was a very low quality of evidence due to serious inconsistency
CH was not included in the network analysis. in the I2 statistic and indirectness of evidence.
Obturation method and pulpectomy success. The SR1 used a
Question 4g. In primary teeth treated with non-vital pulp forest plot to compare the pulpectomy success using Lentulos
therapy, does the timing and/or type of final restoration in- from 12 studies, six using hand pluggers, and seven using
fluence success? syringes. Using Lentulos resulted in 91 percent success versus
Recommendation: The 12-month data showed stainless steel 87 percent using hand pluggers and 87 percent with syringes
crowns (SSCs) versus fillings had comparable success unaffected after 12 months. There was no significant difference in the three
by the timing of when the final restoration was placed. The methods of obturation achieving success. The evidence consists
limited 24-month data suggests that teeth restored with SSCs of indirect comparisons from various types of study designs

(RCTs and observational studies) and different follow-up times. pulpectomy success was adversely affected if treated for trauma
This is a very low quality of evidence due to the very serious or caries unless the tooth was retraumatized.
heterogeneity in the I 2 statistic and indirect comparisons of Summary of findings: The SR1 found 10 studies that assessed
evidence. the success of pulpectomy after trauma or caries. The success
The SR 1 used five RCT studies that directly compared rate of traumatized primary anterior teeth pulpectomy after a
pulpectomy success using Lentulo fills versus syringe fills after minimum of 12 months was 77 percent (122 out of 159) versus
12 months of follow-up. The meta-analysis showed no signi- 87 percent (144 out of 166) for primary incisors with caries.
ficant difference in these success rates. This is a very low No statistical comparison could be made since the evidence
quality of evidence due to the high ROB in some studies and consisted of indirect comparisons from various types of study
very serious inconsistency in the I2 statistic. designs and follow-ups. No GRADE assessment of the quality
Remarks: The overfilling of the canals appears to be related of this evidence was possible.
to a lower success for pulpectomy. The data from various RCT Remarks: From this data,1 incisor pulpectomy success rates
and retrospective studies 18-22 show overfilling the root canals do not appear to be much different if treated due to trauma or
in primary teeth tended to result in lowered success. The type caries after 12 months. In one RCT study, 24 trauma did not
of obturation technique (hand plugger, Lentulo, syringe decrease the success of an incisor pulpectomy unless the incisor
delivery tip) all produce voids when evaluated in vitro and some was retraumatized; then pulpectomy success decreased signifi-
techniques may cause more overfills (Lentulo) than others. 23 cantly to 41 percent.
There were not enough clinical studies to evaluate these effects.
Question 5. In primary teeth treated with pulpectomy, does
Question 4i. In primary teeth treated with pulpectomy, does the type of isolation technique influence success?
the tooth type (incisor, primary first molar, primary second Recommendation: The WG did not find evidence to make a
molar) influence success? recommendation on the type of isolation technique influencing
Recommendation: The WG did not find adequate evidence success. The use of a rubber dam for non-vital procedures is
to make a recommendation on the influence of tooth type on critical to maintaining isolation from saliva, blood, and other
success. Pulpectomy success rates from 13 to 36 months do not contaminants.
seem to be altered if a molar versus an incisor is treated due Summary of findings: All the studies except five used a
to caries. In addition, the pulpectomy success rates for primary rubber dam.1 The five that did not use a rubber dam did not
first molars and primary second molars seem to be comparable. have usable data to evaluate.
Summary of findings: The SR1 used 10 studies to report the Remarks: The use of a rubber dam is accepted as the stan-
success rate of the particular primary tooth treated with dard of care when performing non-vital pulp therapy. It may
pulpectomy and the follow-up time. Three RCTs had a 12- to be unethical to perform a study comparing with and without
36-month follow-up and seven NRSs had a follow-up from use of a rubber dam.
six to 91 months. For teeth treated due to caries and followed
a minimum of 12 months, the incisor success rate was 87 Question 6. In primary teeth treated with LSTR what factors
percent (144 out of 166) and the molar success rate was 89 influence success?
percent (138 out of 155). The success rates for primary first Question 6a. When doing LSTR, how does traditional 3Mix
molars versus second molars were nearly the same (91 percent (with tetracycline) compare to alternate 3Mix (without
[51 out of 56] and 90 percent [69 out of 77], respectively). No tetracycline)?
statistical comparison could be made since the evidence con- Recommendation: Considering the significantly higher
sisted of indirect comparisons from various types of study success of alternate 3Mix and the potential adverse effects of
designs and follow-ups. No GRADE assessment of the quality tetracycline in children, when doing LSTR clinicians should
of this evidence was possible. choose an alternate 3Mix (without tetracycline) over traditional
Remarks: The SR1 data indicated tooth type did not appear 3Mix. (Conditional recommendation, very low quality of
to affect the success rates of primary incisor pulpectomies evidence.)
versus primary molar pulpectomies after 12 months. The suc- Summary of findings: The SR 1 reported the 12-month
cess rate for primary incisors was 87 percent (144 out of 166) data of success from nine RCT studies comparing LSTR using
if treated due to caries versus 89 percent (138 out of 155) for 3Mix with minocycline to five LSTR studies using an alternate
primary molars. antibiotic mixture where a tetracycline was not included. There
was significantly less success statistically (56 percent) using
Question 4J. In incisors that are necrotic as a result of trauma, 3-Mix with a tetracycline versus 3-Mix without tetracycline
is pulpectomy successful? (76 percent). The quality of the evidence for this result was
Recommendation: The WG did not find adequate evidence very low, according to the GRADE at 12 months due to the
to make a recommendation on the influence of trauma on very serious heterogeneity seen in the I 2 statistic, and very
success. The pulpectomy success rate in incisors treated due to serious indirectness due to the indirect comparison.
trauma or caries was comparable. It does not appear that

Remarks: There also was in vitro evidence on this finding. Exfoliation after non-vital pulp treatment. The SR1 reported
Rafatjou25 found that the combination of clindamycin, metro- that, based on Trairatvorakul’s 8 LSTR study, six out of eight
nidazole, and ciprofloxacin was as effective as the combination teeth exhibit abnormal exfoliation after a two-year follow-up.
of minocycline, metronidazole, and ciprofloxacin, with no signi- Grewal’s study10 was the longest LSTR follow-up (36 months).
ficant difference observed in reducing mean bacterial colony It showed that LSTR-treated teeth did not resorb, unlike
counts. untreated contralateral teeth. The SR1 combined nine studies on
pulpectomy, including RCTs and NRSs showing 76 out of 317
Question 6b. When doing LSTR, should the root canals be (24 percent) pulpectomy-treated teeth had early exfoliation,
filed or broached? and 29 out of 319 (nine percent) were overretained compared
Recommendation: When doing LSTR, clinicians may choose to contralateral teeth.
whether or not to file/broach the canals since the success rate Problems from non-vital treatment in primary teeth on the
for each method was not significantly different. (Conditional succedaneous teeth. The SR 1 found only one LSTR study 26
recommendation, very low quality of evidence.) reporting an enamel defect in one out of 71 (one percent) suc-
Summary of findings: The SR 1 reported on 11 RCT and cedaneous teeth. From the SR,1 qualitative data on pulpectomy
NRS studies of LSTR treatment with 12-month results where in five NRSsreported on the presence of enamel defects in
the canals were not filed or broached before placing the anti- succedaneous teeth. The studies indicated the pulpectomy pro-
biotic paste. A meta-analysis compared these 11 studies to four cedure did not cause enamel defects in the succedaneous tooth.
RCT articles on LSTR where the canals were filed and/or Instead, defects were related to the age 27 of the child (younger
broached before the triple antibiotic paste was placed. There was than 4.6 years) when the tooth became infected, excessive
no significant difference in success rate when the canals were preoperative root resorption, 28 or trauma. 18 One pulpectomy
filed or broached before the antibiotic paste placement (72 study27 involving 103 succedaneous teeth found only seven out
percent) versus when the canals were not filed or broached of the 103 (6.8 percent) had a small enamel defect. Grewal10
before the antibiotic paste was placed (62 percent). The quality reported that LSTR teeth followed-up for 36 months were
of the evidence for this result was very low, according to the overretained compared to the conventional pulpectomy treatment
GRADE at 12 months, due to the serious heterogeneity seen in g ro u p, a n d s o m e L S T R t e e t h we re a s s o c i a t e d w i t h
the I2 statistic and very serious indirectness due to the indirect interradicular bone loss surrounding the crown of a permanent
comparison. successor.
Pain. The SR1 reported that qualitative data on postoper-
Question 7. What are the adverse events associated with ative pain after the first 24 to 48 hours was only associated
non-vital pulp therapy in primary teeth? when a non-vital treatment failed. The SR1 could only identify
Recommendation: The WG did not find adequate evidence three studies on immediate postoperative pain during the first
to make a recommendation on adverse events after pulpectomy. 24 hours after pulpectomy. Taking the three studies29-31 together,
Moderate to severe pain after 24 hours from a pulpectomy pro- regardless of the different variables, the SR1 categorized the
cedure appears to be rare. Enamel defects in the succedaneous results into no pain, mild pain, and moderate to severe pain in
tooth replacing a tooth with a pulpectomy seems to be rare, three time intervals: six, 12, and 24 hours posttreatment. The
but retained ZOE filler after pulpectomy exfoliation is not an results at 24 hours showed the following: children having no
uncommon occurrence. LSTR treatment after 36 months from pain (80 percent; 208 out of 261); children with mild pain (12
one report 10 described intraradicular bone loss affecting the percent; 31 out of 261); and children with moderate to severe
permanent tooth. Clinicians should evaluate non-vital pulp pain (eight percent; 22 out of 261). Severe pain from the
treatments for success and adverse events clinically and radio- pulpectomy procedure did not appear to be a major occurrence.
graphically at least every 12 months.
Summary of findings: pulpectomy filler resorption. The qual- Research considerations
itative data from the SR1 on filler resorption from six RCTs For non-vital primary tooth pulp treatment, there are various
and NRSs indicated ZOE resorbs slower than the primary criteria used to grade success. The use of a consistent set of stan-
tooth root in some cases. This may cause the permanent tooth’s dards to report treatment success would help future systematic
path of eruption to be deflected and may result in anterior reviewers compare results. A furcation radiolucency should
crossbite for incisors. The iodoform fillers seemed to resorb at decrease after six months or totally resolve to be assessed a
a faster rate than the root, resulting in the pulpectomy looking success. A static or unchanged radiolucency means the infection
more like a pulpotomy after 12 to 18 months. Seven studies in is still present but not causing clinical symptoms.
the SR1 found that, if the filler is extruded beyond the apex, The WG observed problems with some studies in the
iodoform fillers all seem to resorb but ZOE resorbs slowly and process of compiling the SR.1 Authors should ensure their flow
can take years to resorb. The qualitative data reported that diagrams match their results and data in their tables. Also,
teeth filled with ZOE for the pulpectomy had all or part of the reviewers of articles should insist that data they are reviewing
filler retained in 138 out of 448 teeth (31 percent) based on matches so that future systematic reviewers can extract valid data
data from 13 RCTs and NRSs. for comparison. Flow diagrams should be made mandatory

for publication by journals, and the flow diagram should match The cost of pulp treatment may be contained by using
the CONSORT Flow Diagram for RCTs. effective medicaments, as determined by evidence-based re-
search and detailed in this guideline; however, the only way to
Guideline implementation and recommendation reduce costs overall is to establish dental homes for every child
adherence and implement primary prevention by the child’s parents or
This guideline, the AAPD’s first evidence-based guideline on caregiver. Primary prevention must start early if treatment costs
non-vital pulp therapy, is published in both the journal Pediatric are to be reduced and oral health maintained.
Dentistry and The Reference Manual of Pediatric Dentistry.
Additionally, AAPD members will be notified of the new Workgroup and stakeholders. In December 2018, the
guidelines via social media, newsletters, and presentations. The AAPD Board of Trustees approved a WG nominated by the
guidelines are available as an open-access publication on the Evidence-Based Dentistry Committee to develop a new
AAPD’s website. evidence-based clinical practice guideline on non-vital pulp
Guidelines are used by insurers, patients, and health care therapies in primary teeth with deep caries lesions. The WG
practitioners to determine the quality of care. Adherence to consisted of pediatric dentists in public and private practice
guideline recommendations is measured because it is believed involved in research and education; the stakeholders consisted
following best practices reduces inappropriate care and improves of representatives from general dentistry, governmental and
outcomes. nongovernmental agencies, and international and specialty
Cost-effectiveness of recommendations. The cost- dental organizations.
effectiveness of treatment is based on initial and possible External stakeholders. External and internal stakeholders
retreatment costs of an intervention.32 A cost-analysis for therapies reviewed the document during the process of development of
with proven health benefits and minimal adverse effects is an the guideline. Internal stakeholders also participated in anony-
important consideration for clinicians, patients, and third-party mous surveys to determine the scope and outcomes of the
payors.32 This is especially important when different procedures guideline. All stakeholder comments were considered and
with similar outcomes are available to treat a specific condition, addressed in the WG meetings. It is expected that the publica-
as with non-vital pulp therapies. A research brief covering claims tion and dissemination of the guideline will generate additional
data for all children with private dental insurance does not list dialogue, comments, and feedback from professional, academic,
non-vital pulp therapies in primary teeth as one of top 25 and community stakeholders.
most common procedures performed in children with private Intended users. The target audiences for this guideline
dental benefits, but it lists extractions.33 The few non-vital pulp are dental team members in private, dental school, or public
therapies performed on a population level compared to extrac- health care settings such as pediatric dentists, dental educators,
tion is a cost-effective treatment health issue since extraction general dentists, public health practitioners, policymakers, pro-
may require a space maintainer to prevent space loss and gram managers, third-party insurers, dental students/residents,
malocclusion. However, very limited data exist on the cost- and parents/guardians. The target populations include children
effectiveness of non-vital pulp therapies in the primary dentition needing non-vital pulp therapy in primary teeth.
versus tooth extraction. An extraction alternative may be Guideline updating process. The AAPD’s Evidence-Based
determined based on both cost-effectiveness and quality of life, Dentistry Committee will monitor the biomedical literature
as maintaining the integrity of the arches has many implications to identify new evidence that may impact the current recom-
on function and the development of the occlusion. Pulpectomy mendations. These recommendations will be updated five years
is a procedure reimbursed by both private and federally funded from the time of the last systematic search unless the Evidence-
insurance companies; however, LSTR is not listed as a specifically Based Dentistry Committee determines that an earlier revision
coded procedure. Reimbursement of more conservative or update is warranted.
approaches of pulp therapy aimed at preserving a tooth, such
as a pulpectomy and LSTR, will allow clinicians to make References
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at the time of treatment, as the longest follow-up times of the 2. American Academy of Pediatric Dentistry. Pulp therapy
studies used as a basis for these recommendations are 18 for primary and immature permanent teeth. The Reference
months. Manual of Pediatric Dentistry. Chicago, Ill., USA:
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assessment of pulp inflammation? Pediatr Dent 2018;40 study. Pediatr Dent 1993;15(6):403-7.
(1):37-42. 21. Flaitz CM, Barr ES, Hicks MJ. Radiographic evaluation of
8. Trairatvorakul C, Detsomboonrat P. Success rates of a pulpal therapy for primary anterior teeth. ASDC J Dent
mixture of ciprofloxacin, metronidazole, and minocycline Child 1989;56(3):182-5.
antibiotics used in the non-instrumentation endodontic 22. Sari S, Okte Z. Success rate of Sealapex in root canal treat-
treatment of mandibular primary molars with carious ment for primary teeth: 3-year follow-up. Oral Surg Oral
pulpal involvement. Int J Paediatr Dent 2012;22(3): Med Oral Path Oral Radiol Endod 2008;105(4):e93-e96.
217-27. 23. Memarpour M, Shahidi S, Meshki R. Comparison of dif-
9. Jaya AR, Praveen, Anantharaj A, et al. In vivo evaluation of ferent obturation techniques for primary molars by digital
lesion sterilization and tissue repair in primary teeth pulp radiography. Pediatr Dent 2013;35(3):236-40.
therapy using two antibiotic drug combinations. J Clin 24. Rocha MJ, Cardoso M. Survival analysis of endodontically
Pediatr Dent 2012;37(2):189-91. treated traumatized primary teeth. Dent Traumatol 2007;
10. Grewal N, Sharma N, Chawla S. Comparison of resorption 23(6):340-7.
rate of primary teeth treated with alternative lesion steril- 25. Rafatjou R, Yousefimashouf R, Farhadian M, Afzalsoltani S.
ization and tissue repair and conventional endodontic Evaluation of the antimicrobial efficacy of two combinations
treatment: An in vivo randomized clinical trial. J Indian of drugs on bacteria taken from infected primary teeth
Soc Pedod Prev Dent 2018;36(3):262-7. (in vitro). Eur Arch Paediatr Dent 2019;20(6):609-15.
11. Wankhade AD, Kumar R, Singh RK, Chandra A. Root 26. Hobson P. Pulp treatment of deciduous teeth. 2. Clinical
length determination by different methods in primary investigation. Br Dent J 1970;128(6):275-82.
teeth: An in vivo study. Pediatr Dent 2013;35(2):e38-e42. 27. Stallaert KM, Sigal MJ, Titley KV, Andrews PB. A retro-
12. Coll JA, Josell S, Casper JS. Evaluation of a one- spective study of root canal therapy in non-vital primary
appointment formocresol pulpectomy technique for primary molars. Eur J Paediatr Dent 2016;17(4):295-300.
molars. Pediatr Dent 1985;7(2):123-9. 28. Coll JA, Sadrian R. Predicting pulpectomy success and
13. Rawson TH, Rayes S, Strizich G, Salazar CH. Longitudinal its relationship to exfoliation and succedaneous dentition.
study comparing pulpectomy and pulpotomy treatments Pediatr Dent 1996;18(1):57-63.
for primary molars of Alaska Native children. Pediatr Dent 29. Panchal V, Jeevanandan G, Subramanian EMG. Comparison
2019;41(3):214-20. of post-operative pain after root canal instrumentation
14. Moranker R, Goya A, Gauba K, et al. Manual versus with hand K-files, H-files and rotary Kedo-S files in
rotary instrumentation for primary molar pulpectomies: A primary teeth: A randomised clinical trial. Eur Arch
24-months randomized clinical trial. Pediatr Dent J 2018; Paediatr Dent 2019;20(5)467-72.
28(2):96-102. Available at: “https://www.semanticscholar. 30. Topcuoglu G, Topcuoglu HS, Delikan E, et al. Postoperative
org/paper/Manual-versus-rotary-instrumentation-for- pain after root canal preparation with hand and rotary
primary-A-Morankar-Goyal/fc808b558de6aff5892fd- files in primary molar teeth. Pediatr Dent 2017;39(3):
2bdd84eb934230cd991”. Accessed September 18, 2020. 192-6.

31. Sevekar SA, Gowda SHN. Postoperative pain and flare-ups: 34. Caffrey E, Tate AR, Cashion SW. Are your kids covered?
Comparison of incidence between single and multiple visit Medicaid coverage for essential oral health benefits.
pulpectomy in primary molars. J Clin Diagn Res 2017; Technical brief. September 2017. Pediatric Oral Health
11(3):ZC09-ZC12. Research and Policy Center, American Academy of Pedi-
32. Schwendicke F, Brouwer F, Stolpe M. Calcium hydroxide atric Dentistry. Available at: “https://www.aapd.org/assets/
versus mineral trioxide aggregate for direct pulp capping: 1/7/AreYourKidsCoveredfinal.pdf ”. Accessed September
A cost-effectiveness analysis. J Endod 2015;41(12): 4, 2020.
1969-74.
33. Yarbrough C, Vujicic M, Aravamudhan K, Schwartz S,
Grau B. An analysis of dental spending among children
with private dental benefits. Health Policy Institute Re-
search Brief. American Dental Association. April 2016
(Revised). Available at: “http://www.ada.org/~/media/
ADA/Science%20and%20Research/HPI/Files/HPIBrief
_0316_3.pdf ”. Accessed September 4, 2020. (Archived in
®
WebCite at: “http://www.webcitation.org/6tVCB0KEY”)

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BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE/ COUNSELING AND TREATMENT
Recommendations
Best Practices
“ The best clinical or administrative
practice or approach at the
moment, given the situation, the
consumer’s or community’s needs
and desires, the evidence about
what works for this situation/need/
desire, and the resources available.”

BEST PRACTICES: EXAMINATION, PREVENTION, GUIDANCE / COUNSELING AND TREATMENT
Periodicity of Examination, Preventive Dental

Services, Anticipatory Guidance /Counseling, and
Oral Treatment for Infants, Children, and Adolescents
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Periodicity
2018 of examination, preventive dental services, anticipatory guidance/
counseling, and oral treatment for infants, children, and adolescents.
Purpose
The American Academy of Pediatric Dentistry (AAPD) of all oral conditions, dental disease, and injuries.12-18 The early
intends these recommendations to help practitioners make dental visit to establish a dental home provides a foundation
clinical decisions concerning preventive oral health inter- upon which a lifetime of preventive education and oral health
ventions, including anticipatory guidance and preventive care can be built. The early establishment of a dental home
counseling, for infants, children, and adolescents. has the potential to provide more effective and less costly dental
care when compared to dental care provided in emergency care
Methods facilities or hospitals.19-23 Anticipatory guidance and counsel-
This document was developed by the Clinical Affairs ing are essential components of the dental visit.2,9,10,19,20,22,24-37
Committee and adopted in 1991. This document is a revision Collaborative efforts and effective communication between
of the previous version, last revised in 2013. The update medical and dental homes are essential to prevent oral disease
used electronic database and hand searches of articles in the and promote oral and overall health among children. Medical
medical and dental literature using the terms: periodicity of professionals can play an important role in children’s oral
dental examinations, dental recall intervals, preventive dental health by providing primary prevention and coordinated care.
services, anticipatory guidance and dentistry, caries risk Equally, dentists can improve the overall health of children
assessment, early childhood caries, dental caries prediction, not only by treating dental disease, but also by proactively
dental care cost effectiveness and children, periodontal disease recognizing child abuse, preventing traumatic injuries through
and children and adolescents U.S., pit and fissure sealants, anticipatory guidance, preventing obesity by longitudinal
dental sealants, fluoride supplementation and topical fluoride, dietary counseling, and monitoring of weight status.28 In
dental trauma, dental fracture and tooth, non-nutritive oral addition, dentists can have an important role in assessing
habits, treatment of developing malocclusion, removal of immunization status and developmental milestones for poten-
wisdom teeth, removal of third molars; fields: all; limits: tial delays, as well as making appropriate referral for further
within the last 10 years, humans, English, and clinical trials; neurodevelopmental evaluations and therapeutic services.29
birth through age 18. From this search, 1,884 articles matched The unique opportunity that dentists have to help address
these criteria and were evaluated by title and/or abstract. overall health issues strengthens as children get older since
Information from 49 articles was chosen for review to update frecuency of well child medical visits decreases at the same
this document. When data did not appear sufficient or were time the frecuency of dental recall visits increases. Research
inconclusive, recommendations were based upon expert and/ shows that children aged six- to 12-years are, on average, four
or consensus opinion by experienced researchers and clinicians. times more likely to visit a dentist than a pediatrician.30,31
Background Recommendations
Professional dental care is necessary to maintain oral health.1 This document addresses periodicity and general principles of
The AAPD emphasizes the importance of initiating professional examination, preventive dental services, anticipatory guidance/
oral health intervention in infancy and continuing through counseling, and oral treatment for children who have no
adolescence and beyond.2 The periodicity of professional oral contributory medical conditions and are developing normally.
health intervention and services is based on a patient’s individ- Accurate, comprehensive, and up-to-date medical, dental, and
ual needs and risk indicators.3-8 Each age group, as well as each
individual child, has distinct developmental needs to be
ABBREVIATIONS
addressed at specific intervals as part of a comprehensive eval- AAPD: American Academy Pediatric Dentistry. ECC: Early child-
uation.2,9-11 Continuity of care is based on the assessed needs hood caries. SHCN: Special health care needs.
of the individual patient and assures appropriate management

social histories are necessary for correct diagnosis and effective Caries-risk assessment
treatment planning. Recommendations may be modified to Risk assessment is a key element of contemporary preventive
meet the unique requirements of patients with special health care for infants, children, adolescents, and persons with
care needs (SHCN).32 SHCN. It should be carried out as soon as the first primary
teeth erupt and be reassessed periodically by dental and med-
Clinical oral examination ical providers.6,25 Its goal is to prevent disease by (1) identifying
The first examination is recommended at the time of the eruption children at high risk for caries, (2) developing individualized
of the first tooth and no later than 12 months of age.2,19,20,22 preventive measures and caries management, as well as (3)
The developing dentition and occlusion should be monitored aiding the practitioner in determining appropriate periodicity
throughout eruption at regular clinical examinations.27 Evidence- of services.25,52,53 Given that the etiology of dental caries is
based prevention and early detection and management of multifactorial and complex, current caries-risk assessment
caries/oral conditions can improve a child’s oral and general models entail a combination of factors including diet, fluoride
health, well-being, and school readiness.5,24,33-36 It has been exposure, host susceptibility, and microflora analysis and
reported that the number and cost of dental procedures among consideration of how these factors interact with social, cultural,
high-risk children is less for those seen at an earlier age versus and behavioral factors. More comprehensive models that
later, confirming the fact that the sooner a child is seen by a include social, political, psychological, and environmental
dentist, the less treatment needs they are likely to have in the determinants of health also are available.54-57 Caries risk assess-
future.37 On the other hand, delayed diagnosis of dental di- ment forms and caries management protocols are available and
sease can result in exacerbated problems which lead to more aim to simplify and clarify the process.25,58,59
extensive and costly care.8,33,38-41 Early diagnosis of developing Sufficient evidence demonstrates certain groups of children
malocclusions may allow for timely therapeutic intervention.9,27 at greater risk for development of early childhood caries
Components of a comprehensive oral examination include (ECC) would benefit from infant oral health care.24,33,60-64
assessment of: Infants and young children have unique caries-risk factors
• general health/growth. such as ongoing establishment of oral flora and host defense
• pain. systems, susceptibility of newly erupted teeth, and development
• extraoral soft tissues. of dietary habits. Because the etiology of ECC is multi-
• temporomandibular joints. factorial and significantly influenced by health behaviors, 65
• intraoral soft tissues. preventive messages for expectant parents and parents of very
• oral hygiene and periodontal health. young children should target factors known to place children
• intraoral hard tissues. at a higher risk for developing caries (e.g., early Mutans
• developing occlusion. streptococci transmssion, poor oral hygiene habits, nighttime
• caries risk. feeding, high sugar consumption frequency). 24,33,57,66
• behavior of child. Motivational problems may develop when parents/patients
are not interested in changing behaviors or feel that the changes
Based upon the visual examination, the dentist may employ require excessive effort. Therefore, it is important that health
additional diagnostic aids (e.g., radiographs, photographs, pulp care professionals utilize preventive approaches based on
vitality testing, laboratory tests, study casts).8,13,42-44 psychological and behavioral strategies. Moreover, they should
The interval of examination should be based on the child’s be sensitive to how they can effectively communicate their
individual needs or risk status/susceptibility to disease; some recommendations so that parents/patients can perceive their
patients may require examination and preventive services at recommendations as behaviors worth pursuing. Two examples
more or less frequent intervals, based upon historical, clinical, of effective motivational approaches used for caries prevention
and radiographic findings.4,7,8,16,18,25,45-48 Caries and its sequelae that share similar psychological philosophies are motivational
are among the most prevalent health problems facing infants, interviewing and self-determination theory.67-73
children, and adolescents in America. 49 Caries lesions are Studies consistently have reported caries experience in
cumulative and progressive and, in the primary dentition, are the primary dentition as a predictor of future caries. 74 Early
highly predictive of caries occurring in the permanent denti- school-aged children are at a transitional phase from primary
tion.6,50 Reevaluation and reinforcement of preventive activities to mixed dentition. These children face challenges such as
contribute to improved instruction for the caregiver of the unsupervised toothbrushing and increased consumption of
child or adolescent, continuity of evaluation of the patient’s cariogenic foods and beverages while at school, placing them
health status, and repetitive exposure to dental procedures, at a higher risk for developing caries.75-77 Therefore, special
potentially allaying anxiety and fear for the apprehensive attention should be given to school-aged children regarding
child or adolescent.51 Individuals with SHCN may require their oral hygiene and dietary practices.
individualized preventive and treatment strategies that take Adolescence can be a time of heightened caries activity due
into consideration the unique needs and disabilities of the to an increased number of tooth surfaces in the permanent
patient.32 dentition and intake of cariogenic substances, as well as low

priority for oral hygiene procedures.9,55,56 Risk assessment can Fluoride supplementation should be considered for children
assure preventive care (e.g., water fluoridation, professional at moderate to high caries risk when fluoride exposure is not
and home-use fluoride and antimicrobial agents, frequency of optimal. 85 Determination of dietary fluoride sources (e.g.,
dental visits) is tailored to each individual’s needs and direct drinking water, toothpaste, foods, beverages) before prescrib-
resources to those for whom preventive interventions pro- ing supplements is required and can help reduce intake of
vide the greatest benefit.9 Because a child’s risk for developing excess fluoride.85 In addition, supplementation should be in
dental disease can change over time due to changes in habits accordance with the guidelines recommended by the AAPD85
(e.g., diet, home care), oral microflora, or physical condition, and the American Dental Association93,94.
risk assessment must be documented and repeated regularly
and frequently to maximize effectiveness.11,25 Radiographic assessment
Radiographs are a valuable adjunct in the oral health care of
Prophylaxis and professional topical fluoride treatment infants, children, and adolescents to diagnose and monitor oral
The interval for frequency of professional preventive services diseases and evaluate dentoalveolar trauma, as well as monitor
is based upon assessed risk for caries and periodontal dis- dentofacial development and the progress of therapy.45 Timing
ease. 3,4,7,8,10,11,25,58,59,60 Prophylaxis aids in plaque, stain, and of initial radiographic examination should not be based on
calculus removal, as well as in educating the patient on oral the patient’s age, but upon each child’s individual circum-
hygiene techniques and facilitating the clinical examina- stances.45,46 The need for dental radiographs can be determined
tion.10 Gingivitis, which is nearly universal in children and only after consideration of the patient’s medical and dental
adolescents, usually responds to thorough removal of bac- histories, completion of a thorough clinical examination, and
terial deposits and improved oral hygiene. 47,79,80 Hormonal assessment of the patient’s vulnerability to environmental
fluctuations, including those occurring during the onset of factors that affect oral health.45 Every effort must be made to
puberty, can modify the gingival inflammatory response to minimize the patient’s radiation exposure by applying good
dental plaque.47,48,81 Children can develop any of the several radiological practices (e.g., use of protective aprons and
forms of periodontitis, with aggressive periodontitis occurring thyroid collars, when appropriate) and by following the as low
more commonly in children and adolescents than as reasonably achievable (ALARA principle).45
adults.47,48,80
Children who exhibit higher risk of developing caries and/ Anticipatory guidance/counseling
or periodontal disease would benefit from recall appointments Anticipatory guidance is the process of providing practical
at greater frequency than every six months (e.g., every three and developmentally-appropriate information about children’s
months).3,4,8,10,11,25,59 This allows increased professional fluoride health to prepare parents for significant physical, emotional,
therapy application and improvement of oral health by and psychological milestones.2,9,19,20,95,96 Individualized discus-
demonstrating proper oral hygiene techniques, in addition to sion and counseling should be an integral part of each visit.
microbial monitoring, antimicrobial therapy reapplication, and Topics to be included are oral/dental development and growth,
reevaluating behavioral changes for effectiveness.3,10,48,59,82-84 An speech/language development, nonnutritive habits, diet and
individualized preventive plan increases the probability of good nutrition, injury prevention, tobacco product use, substance
oral health by demonstrating proper oral hygiene methods/ use/abuse, intraoral/perioral piercing, and oral jewelry/
techniques and removing plaque, stain, and calculus.4,48,84 accessories.2,9,15,19,27,95-102,213,214
Fluoride contributes to the prevention, inhibition, and re- Anticipatory guidance regarding the characteristics of a
versal of caries.85-87 Professional topical fluoride treatments normal healthy oral cavity should occur during infant oral
should be based on caries risk assessment.19,25,86,89 Plaque and health visits and throughout follow-up dental visits. This
pellicle are not a barrier to fluoride uptake in enamel.10 Con- allows parents to measure against any changes such as, but not
sequently, there is no evidence of a difference in caries rates or limited to, growth delays, traumatic injuries, and poor oral
fluoride uptake in patients who receive rubber cup prophylaxis hygiene or presence of caries lesions. Tooth development and
or a tooth-brush prophylaxis before fluoride treatment.88,89 chronology of eruption can help parents better understand the
Precautionary measures should be taken to prevent swallowing implications of delayed or accelerated tooth emergence and
of any professionally-applied topical fluoride. Children at high the role of fluorides in newly erupted teeth that may be at
caries risk should receive greater frequency of professional higher risk of developing caries, especially during the post-
fluoride applications (e.g., every three months).85,89-92 Ideally, eruption maturation process.95 Assessment of developmental
this would occur as part of a comprehensive preventive program milestones (e.g., fine/gross motor skills, language, social
in a dental home.19 interactions) is crucial for early recognition of potential delays
and appropriate referral to therapeutic services.29 Speech and
Fluoride supplementation language are integral components of a child’s early develop-
The AAPD encourages optimal fluoride exposure for every ment.101 Abnormal delays in speech and language production
child, recognizing fluoride in the community water supplies as can be recognized early with referral made to address these
the most beneficial and cost-effective preventive intervention.85 concerns. Communication and coordination of appliance

therapy with a speech and language professional can assist Traumatic dental injuries that occur in preschool, school-
in the timely treatment of speech disorders.101 age children, and young adults comprise five percent of all
Oral habits (e.g., nonnutritive sucking: digital and pacifier injuries for which treatment is sought.110 Facial trauma that
habits; bruxism; tongue thrust swallow and abnormal tongue results in fractured, displaced, or lost teeth can have significant
position; self-injurious/self-mutilating behavior) may apply negative functional, esthetic, and psychological effects on
forces to teeth and dentoalveolar structures. Although early children. 111 Practitioners should provide age-appropriate
use of pacifiers and digit sucking are considered normal, habits injury prevention counseling for orofacial trauma.15,96 Initially,
of sufficient frequency, intensity, and duration can contribute discussions would include advice regarding play objects,
to deleterious changes in occlusion and facial development.27 pacifiers, car seats, and electrical cords. As motor coordination
It is important to discuss the need for early pacifier and digit develops and the child grows older, the parent/patient should
sucking, then the need to wean from the habits before maloc- be counseled on additional safety and preventive measures,
clusion or skeletal dysplasias occur.27 Early dental visits provide including use of athletic mouthguards for sporting activities.
an opportunity to encourage parents to help their children Dental injuries could have improved outcomes not only if the
stop sucking habits by age three years or younger. For school- public were aware of first-aid measures and the need to seek
aged children and adolescent patients, counseling regarding immediate treatment, but also if the injured child had access
any existing habits (e.g., fingernail biting, clenching, bruxism) to emergency care at all times. Caregivers report that, even
is appropriate.27 Parents should be provided with informa- though their children had a dental home, they have experi-
tion regarding the potential immediate and long-term effects enced barriers to care when referred outside of the dental
on the craniofacial complex and dentition from a habit. If home for emergency services.112 Barriers faced by caregivers
treatment is indicated, it can include patient/parent counsel- include availability of providers and clinics for delivery of
ing, behavior modification techniques, appliance therapy, or emergency care and the distance one must travel for treat-
referral to other providers including, but not limited to, ment. Therefore, it is important that all primary care providers
orthodontists, psychologists, or otolaryngologists.27 inform parents about ways to access emergency care for
Oral hygiene counseling involves the parent and patient. dental injuries and provide telephone numbers to access a
Initially, oral hygiene is the responsibility of the parent. As dentist, including for after-hours emergency care.113
the child develops, home care is performed jointly by parent Smoking and smokeless tobacco use almost always are
and child. When a child demonstrates the understanding and initiated and established in adolescence.114-116 In 2016, 7.2
ability to perform personal hygiene techniques, the health percent of middle school students and 20.2 percent of high
care professional should counsel the child. The effectiveness of school students reported current tobacco product use. 117 The
home care should be monitored at every visit and includes a most common tobacco products used by middle school and
discussion on the consistency of daily oral hygiene preventive high school students were reported to be e-cigarettes, cigarettes,
activities, including adequate fluoride exposure.3,4,9,25,85,103 cigars, smokeless tobacco, hookahs, pipe tobacco, and bidis
The development of dietary habits and childhood food (unfiltered cigarettes from India).117 E-cigarette use rose from
preferences appears to be established early and may affect the 1.5 percent to 16.0 percent among high school students
oral health as well as general health and well-being of a and from 0.6 percent to 5.3 percent among middle school
child.104 The establishment of a dental home no later than students from 2011 to 2015. 117 During this time period,
12 months of age allows dietary and nutrition counseling to children may be exposed to opportunities to experiment
occur early. This helps parents to develop proper oral health with other substances that negatively impact their health
habits early in their child’s life, rather than trying to change and well-being. Practitioners should provide education re-
established unhealthy habits later. During infancy, counseling garding the serious health consequences of tobacco use and
should focus on breastfeeding, bottle or no-spill cup usage, exposure to second hand smoke. 97,117 The practitioner may
concerns with nighttime feedings, frequency of in-between need to obtain information regarding tobacco use and alcohol/
meal consumption of sugar-sweetened beverages (e.g., sweet- drug abuse confidentially from an adolescent patient. 9,100
ened milk, 100 percent juice, soft drinks, fruit drinks, sports When tobacco or substance abuse has been identified, practi-
drinks) and snacks, as well as special diets.26 Excess consump- tioners should provide brief interventions for encouragement,
tion of carbohydrates, fats, and sodium contribute to poor support, and positive reinforcement for avoiding substance
systemic health.105-107 Dietary analysis and the role of dietary use. 97,100 If indicated, dental practitioners should provide
choices on oral health, malnutrition, and obesity should be referral to primary care providers or behavioral-health/addiction
addressed through nutritional and preventive oral health specialists for assessment and/or treatment of substance use
counseling at periodic visits.26,108 The U.S. Departments of disorders.100
Health and Human Services and Agriculture provide dietary Complications from intraoral/perioral piercings can range
guidelines every five years to help Americans two years of from pain, infection, and tooth fracture to life-threatening
age and older make healthy choices to help prevent chronic conditions of bleeding, edema, and airway obstruction. 99
diseases and guidance for parents and their children and Education regarding pathologic conditions and sequelae
promote a healthy diet.109 associated with piercings should be initiated for the preteen

child/parent and reinforced during subsequent periodic preventive care appointments. Sealants should be monitored
visits.The AAPD strongly opposes the practice of piercing and repaired or replaced as needed.121-123
intraoral and perioral tissues and use of jewelry on intraoral
and perioral tissues due to the potential for pathological con- Third molars
ditions and sequelae associated with these practices.99 Panoramic or periapical radiographic assessment is indicated
during late adolescence to assess the presence, position, and
Treatment of dental disease/injury development of third molars. 45,46 A decision to remove or
Health care providers who diagnose oral disease or trauma retain third molars should be made before the middle of the
should either provide therapy or refer the patient to an third decade. 124,125 Impacted third molars are potentially
appropriately-trained individual for treatment.118 Immediate pathologic. Pathologic conditions generally are more common
intervention is necessary to prevent further dental destruction, with an increase in age. Evaluation and treatment may re-
as well as more widespread health problems. Postponed quire removal, exposure, and/or repositioning. In selected
treatment can result in exacerbated problems that may lead cases, long-term clinical and radiographic monitoring may
to the need for more extensive care.22,34,35,40 Early intervention be needed. Treatment should be provided before pathologic
could result in savings of health care dollars for individuals, conditions adversely affect the patient’s oral and/or systemic
community health care programs, and third-party payors.21,29,30,34 health. 119,124,125 Consideration should be given to removal
when there is a high probability of disease or pathology and/
Treatment of developing malocclusion or the risks associated with early removal are less than the
Guidance of eruption and development of the primary, mixed, risks of later removal.14,119,125 Postoperative complications for
and permanent dentitions is an integral component of com- removal of impacted third molars are low when performed
prehensive oral health care for all pediatric dental patients.27 at an early age.126 A Cochrane review in 2012 reported there
Dentists have the responsibility to recognize, diagnose, and was no difference in late lower incisor crowding with removal
manage or refer abnormalities in the developing dentition or retention of asymptomatic impacted third molars.127
as dictated by the complexity of the problem and the individ-
ual clinician’s training, knowledge, and experience.118 Early Referral for regular and periodic dental care
diagnosis and successful treatment of developing maloc- As adolescent patients approach the age of majority, it is
clusions can have both short-term and long-term benefits, important to educate the patient and parent on the value
while achieving the goals of occlusal harmony and function of transitioning to a dentist who is knowledgeable in adult
and dentofacial esthestics.104-108 Early treatment is beneficial oral health care. At the time agreed upon by the patient,
for many patients, but is not indicated for every patient. parent, and pediatric dentist, the patient should be referred
When there is a reasonable indication that an oral habit will to a specific practitioner in an environment sensitive to the
result in unfavorable sequelae in the developing permanent adolescent’s individual needs.9,128 Until the new dental home
dentition, any treatment must be appropriate for the child’s is established, the patient should maintain a relationship with
development, comprehension, and ability to cooperate. Use the current care provider and have access to emergency serv-
of an appliance is indicated only when the child wants to ices. For the patient with SHCN, in cases where it is not
stop the habit and would benefit from a reminder.27 At each possible or desired to transition to another practitioner, the
stage of occlusal development, the objectives of intervention/ dental home can remain with the pediatric dentist and
treatment include: (1) reversing adverse growth, (2) preventing appropriate referrals for specialized dental care should be
dental and skeletal disharmonies, (3) improving esthetics of recommended when needed.128 Proper communication and
the smile, (4) improving self-image, and (5) improving the records transfer allow for consistent and continuous care for
occlusion.27 the patient.42
Sealants Recommendations by age

A 2016 systematic review concluded sealants are effective in Six to 12 months
preventing and arresting pit-and-fissure occlusal caries lesions 1. Complete the clinical oral examination with adjunctive
of primary and permanent molars in children and adolescents diagnostic tools (e.g., radiographs as determined by
and can minimize the progression of noncavitated occlusal child’s history, clinical findings, and susceptibility to oral
caries lesions.120 They are indicated for primary and permanent disease) to assess oral growth and development, pathology,
teeth with pits and fissures that are predisposed to plaque and/or injuries; provide diagnosis.
retention.121 At-risk pits and fissures should be sealed as soon 2. Complete a caries risk assessment.
as possible. Because caries risk may increase at any time during 3. Provide oral hygiene counseling for parents, including
a patient’s life due to changes in habits (e.g., dietary, home the implications of the oral health of the caregiver.
care), oral microflora, or physical condition, unsealed teeth 4. Clean teeth and remove supra- and sub-gingival stains
subsequently might benefit from sealant application.122 The or deposits as indicated.
need for sealant placement should be reassessed at periodic

5. Assess the child’s systemic and topical fluoride status 2. Provide substance abuse counseling (e.g., smoking,
(including type of infant formula used, if any, and expo- smokeless tobacco) and/or referral to primary care pro-
sure to fluoridated toothpaste) and provide counseling viders or behavioral health/addiction specialists if
regarding fluoride. indicated.
6. Assess appropriateness of feeding practices, including 3. Provide counseling on intraoral/perioral piercing.
bottle and breast-feeding, and provide counseling as
indicated; provide dietary counseling related to oral 12 years and older
health. 1. Repeat the procedures for ages six to 12 years every six
7. Provide age-appropriate injury prevention counseling for months or as indicated by the child’s individual needs
orofacial trauma. or risk status/susceptibility to disease.
8. Provide counseling for nonnutritive oral habits (e.g., 2. During late adolescence, assess the presence, position, and
digit, pacifiers). development of third molars, giving consideration to
9. Provide required treatment and/or appropriate referral removal when there is a high probability of disease or
for any oral diseases or injuries. pathology and/or the risks associated with early removal
10. Provide anticipatory guidance. are less than the risks of later removal.
11. Assess overall growth and development, and make appro- 3. At an age determined by patient, parent, and pediatric
priate referral to therapeutic services if needed. dentist, refer the patient to a general dentist for conti-
12. Consult with the child’s physician as needed. nuing oral care.
13. Determine the interval for periodic reevaluation.
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Recommended Dental Periodicity Schedule for Pediatric Oral Health Assessment,
242
Preventive Services, and Anticipatory Guidance/Counseling
Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are developing normally. These recom-
mendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from normal. The American Academy of Pediatric
Dentistry emphasizes the importance of very early professional intervention and the continuity of care based on the individualized needs of the child. Refer to the text of
this guideline for supporting information and references. Refer to the text in the Recommendations on the Periodicity of Examination, Preventive Dental Services, Anticipatory
Guidance, and Oral Treatment for Infants, Children, and Adolescents (www.aapd.org/policies/ ) for supporting information and references.
BEST PRACTICES: RECOMMENDED
AGE
®
6 TO 12 MONTHS 12 TO 24 MONTHS 2 TO 6 YEARS 6 TO 12 YEARS 12 YEARS

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BEST PRACTICES: CARIES-RISK ASSESSMENT AND MANAGEMENT
Caries-risk Assessment and Management for

Infants, Children, and Adolescents
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Caries-risk
2019 assessment and management for infants, children, and adolescents.
Purpose Caries-risk assessment models currently involve a combina-

The American Academy of Pediatric Dentistry recognizes that tion of factors including diet, fluoride exposure, a susceptible
caries-risk assessment and management protocols, also called host, and microflora that interplay with a variety of social,
care pathways, can assist clinicians with decisions regarding cultural, and behavioral factors. Caries-risk assessment is the
treatment based upon child’s age, caries risk, and patient determination of the likelihood of the increased incidence of
compliance and are essential elements of contemporary clinical caries (i.e., the number of new cavitated or incipient lesions)
care for infants, children, and adolescents. These recommen- during a certain time period9 or the likelihood that there will
dations are intended to educate healthcare providers and other be a change in the size or activity of lesions already present.
interested parties on the assessment of caries risk in contem- With the ability to detect caries in its earliest stages (i.e.,
porary pediatric dentistry and aid in clinical decision-making non-cavitated or white spot lesions), health care providers can
regarding evidence- and risk-based diagnostic, fluoride, dietary, help prevent cavitation.3
and restorative protocols. Caries risk indicators are variables that are thought to
cause the disease directly (e.g., microflora) or have been shown
Methods useful in predicting it (e.g., life-time poverty, low health
This document was developed by the Council on Clinical literacy) and include those variables that may be considered
Affairs and adopted in 20021 and last revised in 2014 2. To protective factors. The most commonly used caries risk indi-
update this best practices document, an electronic search of cators include presence of caries lesions, low salivary flow,
systematic reviews/meta-analyses or expert panels was conduc- visible plaque on teeth, high frequency sugar consumption,
ted from 2012 to 2018 using the terms: caries risk assessment, presence of appliance in the mouth, health challenges, socio-
diet, sealants, fluoride, radiology, non-restorative treatment, demographic factors, access to care, and cariogenic microflora.3
active surveillance, caries prevention. There were four systematic Protective factors in caries risk include a child’s receiving
reviews that informed this update on caries risk assessment.3-6 optimally-fluoridated water, having teeth brushed daily with
There were 10 systematic reviews and clinical practice guide- fluoridated toothpaste, receiving topical fluoride from a health
lines that inform this update on care pathways for caries.7-16 professional, and having regular dental care.3
When data did not appear sufficient or were inconclusive, Some issues with the current risk indicators include past
recommendations were based upon expert and/or consensus caries experience is not particularly useful in young children
opinion by experienced researchers and clinicians. and activity of lesions may be more important than number
of lesions. Low salivary flow is difficult to measure and may
Background not be relevant in young children.17 Frequent sugar consump-
Caries-risk assessment tion is hard to quantitate. Socio-demographic factors are just a
Risk assessment procedures used in medical practice generally proxy for various exposures/behaviors which may affect caries
have sufficient data to accurately quantitate a person’s disease risk. Predictive ability of various risk factors across the life span
susceptibility and allow for preventive measures. However, in and how risk changes with age have not been determined.3
dentistry there still is a lack of sufficiently validated multivari- Furthermore, genome-level risk factors may account for sub-
ate screening tools to determine which children are at a higher stantial variations in caries risk.3
risk for dental caries.5,6 Nevertheless, caries-risk assessment: Risk assessment tools can aid in the identification of reliable
1. fosters the treatment of the disease process instead of predictors and allow dental practitioners, physicians, and other
treating the outcome of the disease. non-dental health care providers to become more actively
2. allows an understanding of the disease factors for a involved in identifying and referring high-risk children. Tables
specific patient and aids in individualizing preventive 1 and 2 incorporate available evidence into practical tools to
discussions. assist dental practitioners, physicians, and other non-dental
3. individualizes, selects, and determines frequency of health care providers in assessing levels of risk for caries devel-
preventive and restorative treatment for a patient. opment in infants, children, and adolescents. As new evidence
4. anticipates caries progression or stabilization.

emergences, these tools can be refined to provide greater intervention. Decisions for intervention often were learned
predictably of caries in children prior to disease initiation. from unstandardized dental school instruction and then
Furthermore, the evolution of caries-risk assessment tools and refined by clinicians over years of practice.
care pathways can assist in providing evidence for and justi- It is now known that surgical intervention of dental caries
fying periodicity of services, modification of third-party alone does not stop the disease process. Additionally, many
involvement in the delivery of dental services, and quality of lesions do not progress, and tooth restorations have a finite
care with outcomes assessment to address limited resources longevity. Therefore, modern management of dental caries
and work-force issues. should be more conservative and includes early detection of
non-cavitated lesions, identification of an individual’s risk
Care pathways for caries management for caries progression, understanding of the disease process
Care pathways are documents designed to assist in clinical for that individual, and active surveillance to apply preven-
decision-making; they provide criteria regarding diagnosis and tive measures and monitor carefully for signs of arrest or
treatment and lead to recommended courses of action.8 The progression.
pathways are based on evidence from current peer-reviewed Care pathways for children further refine the decisions
literature and the considered judgment of expert panels, as concerning individualized treatment and treatment thresholds
well as clinical experience of practitioners. Care pathways for based on a specific patient’s risk levels, age, and compliance
caries management in children aged 0-2 and 3-5 years old with preventive strategies (Tables 3 and 4). Such clinical path-
were first introduced in 2011.18 Care pathways are updated ways yield greater probability of success, fewer complications,
frequently as new technologies and evidence develop. and more efficient use of resources than less standardized
Historically, the management of dental caries was based treatment.8
on the notion that it was a progressive disease that eventually Content of the present caries management protocol is
destroyed the tooth unless there was surgical/restorative based on results of systematic reviews and expert panel
Table 1. Caries-risk Assessment Form for 0-5 Years Old24
Factors High risk Moderate risk Low risk
Risk factors, social/biological

Mother/primary caregiver has active dental caries Yes
Parent/caregiver has life-time of poverty, low health literacy Yes
Child has frequent exposure (>3 times/day) between-meal sugar-containing
Yes
snacks or beverages per day
Child uses bottle or non-spill cup containing natural or added sugar
Yes
frequently, between meals and/or at bedtime
Child is a recent immigrant Yes
Child has special health care needs Yes
Protective factors
Child receives optimally-fluoridated drinking water or fluoride supplements Yes
Child has teeth brushed daily with fluoridated toothpaste Yes
Child receives topical fluoride from health professional Yes
Child has dental home/regular dental care Yes
Clinical findings
Child has non-cavitated (incipient/white spot) caries or enamel defects Yes
Child has visible cavities or fillings or missing teeth due to caries Yes
Child has visible plaque on teeth Yes
Circling those conditions that apply to a specific patient helps the practitioner and parent understand the factors that contribute to
or protect from caries. Risk assessment categorization of low, moderate, or high is based on preponderance of factors for the individual.
However, clinical judgment may justify the use of one factor (e.g., frequent exposure to sugar-containing snacks or beverages, more than
one decayed missing filled surfaces [dmfs]) in determining overall risk.
Overall assessment of the child’s dental caries risk: High Moderate Low
Adapted with permission from the California Dental Association, Copyright © October 2007.

Table 2. Caries-risk Assessment Form for ≥6 Years Old 25

(For Dental Providers)
Factors High risk Moderate risk Low risk
Risk factors, social/biological

Patient has life-time of poverty, low health literacy Yes
Patient has frequent exposure (>3 times/day) between-meal sugar-containing
Yes
snacks or beverages per day
Child is a recent immigrant Yes
Patient has special health care needs Yes
Protective factors
Patient receives optimally-fluoridated drinking water Yes
Patient brushes teeth daily with fluoridated toothpaste Yes
Patient receives topical fluoride from health professional Yes
Patient has dental home/regular dental care Yes
Clinical findings
Patient has ≥1 interproximal caries lesions Yes
Patient has active non-cavitated (white spot) caries lesions or enamel defects Yes
Patient has low salivary flow Yes
Patient has defective restorations Yes
Patient wears an intraoral appliance Yes
Circling those conditions that apply to a specific patient helps the practitioner and patient/parent understand the factors that contribute to
or protect from caries. Risk assessment categorization of low, moderate, or high is based on preponderance of factors for the individual.
However, clinical judgment may justify the use of one factor (e.g., interproximal lesions, low salivary flow) in determining overall risk.
Overall assessment of the dental caries risk: High Moderate Low
Adapted with permission from the California Dental Association, Copyright © October 2007.
Table 3. Example of a Caries Management Pathways for 0-5 Years Old
Interventions
Risk Category Diagnostics Fluoride Dietary Sealants Restorative
Counseling
Low risk – Recall every six to 12 – Drink optimally fluoridated Yes Yes – Surveillance
months water
– Radiographs every 12 – Twice daily brushing with
to 24 months fluoridated toothpaste
Moderate risk – Recall every six months – Drink optimally fluoridated Yes Yes – Active surveillance of non-
– Radiographs every six water cavitated (white spot)
to 12 months – Twice daily brushing with caries lesions
fluoridated toothpaste – Restore of cavitated or
– Fluoride supplements enlarging caries lesions
– Professional topical treatment
every six months
High risk – Recall every three months – Drink optimally fluoridated Yes Yes – Active surveillance of non-
months – Twice daily brushing with caries lesions
– Professional topical treatment enlarging caries lesions
every three months
– Silver diamine fluoride on
cavitated lesions
Refer to notes below Table 4.

recommendations that provide better understanding of and (prevention therapies and close monitoring) of enamel lesions
recommendations for diagnostic, preventive, and restorative is based on the concept that treatment of disease may only be
treatments. Recommendations for the use of fluoridated necessary if there is disease progression,22 and that caries can
toothpaste are based on the three systematic reviews,9,11,12 arrest without treatment.23
and dietary fluoride supplements are based on the Centers Other approaches to the assessment and treatment of
for Disease Control and Prevention’s fluoride guidelines;19 dental caries will emerge with time and, with evidence of
professionally-applied and prescription strength home-use effectiveness, may be included in future guidelines on caries-
topical fluoride are based on two systematic reviews;10,12 the risk assessment and care pathways.
use of silver diamine fluoride to arrest caries lesions also is
based on two systematic reviews.13,14 Radiographic diagnos- Recommendations
tic recommendations are based on the uniform guidelines 1. Dental caries-risk assessment, based on a child’s age, social/
from the three national organizations.7 Recommendations biological factors, protective factors, and clinical findings,
for pit and fissure sealants, especially regarding primary teeth, should be a routine component of new and periodic
are based on the American Dental Association Council on examinations by oral health and medical providers.
Scientific Affairs’ systematic review of the use of pit-and-fissure 2. While there is not enough information at present to have
sealants.15 Dietary interventions are based on a systematic quantitative caries-risk assessment analyses, estimating
review of strategies to reduce sugar-sweetened beverages.16 children at low, moderate, and high caries risk by a pre-
Caries risk is assessed at both the individual level and tooth ponderance of risk and protective factors will enable a
level. Treatment of caries with interim therapeutic restorations more evidence-based approach to medical provider referrals,
is based on the American Academy of Pediatric Dentistry as well as establish periodicity and intensity of diagnostic,
policy and recommended best practices.20,21 Active surveillance preventive, and restorative services.
Table 4. Example of a Caries Management Pathways for ≥6 Years Old
Interventions
Risk Category Diagnostics Fluoride Dietary Sealants Restorative
Counseling
Low risk – Recall every six to 12 – Drink optimally fluoridated Yes Yes – Surveillance
months water
– Radiographs every 12 – Twice daily brushing with
to 24 months fluoridated toothpaste
Moderate risk – Recall every six months – Drink optimally fluoridated Yes Yes – Active surveillance of non-
to 12 months – Twice daily brushing with caries lesions
– Fluoride supplements enlarging caries lesions
– Professional topical treatment
every six months
High risk – Recall every three months – Drink optimally fluoridated Yes Yes – Active surveillance of non-
months – Brushing with 0.5 percent caries lesions
fluoride gel/paste – Restore of cavitated or
– Professional topical treatment enlarging caries lesions
every three months
– Silver diamine fluoride on
cavitated lesions
Notes for caries management pathways tables:

Twice daily brushing: Parental supervision of a “smear” amount of fluoridated toothpaste twice daily for children under age 3, pea-size
amount for children ages 3-6.
Optimize dietary fluoride levels: Ideally by consuming optimally-fluoridated water; alternatively by dietary fluoride supplements, in a
non-fluoridated area, for children at high caries risk.
Surveillance and active surveillance: Periodic monitoring for signs of caries progression and active measures by parents and oral health
professionals to reduce cariogenic environment and monitor possible caries progression.
Silver diamine fluoride: Use of 38 percent silver diamine fluoride to assist in arresting caries lesions. Informed consent, particularly
highlighting expected staining of treated lesions.
Interim therapeutic restorations: also may be called protective restorations.20
Sealants: Although studies report unfavorable cost/benefit ratio for sealant placement in low caries risk children, expert opinion favors
sealants in permanent teeth of low risk children based on possible changes in risk over time and differences in tooth anatomy. The
decision to seal primary and permanent molars should account for both the individual level and tooth level risk.

3. Care pathways, based on a child’s age and caries risk, 12. Scottish Intercollegiate Guidelines Network: SIGN 138:
provide health providers with criteria and protocols for Dental interventions to prevent caries in children, March
determining the types and frequency of diagnostic, 2014. Available at: “https://www.sign.ac.uk/assets/sign
preventive, and restorative care for patient specific man- 138.pdf ”. Accessed February 12, 2019. (Archived by
agement of dental caries. ®
WebCite at: “http://www.webcitation.org/768Bl4pgr”)
13. Crystal YO, Marghalani AA, Ureles SD, et al. Use of
References silver diamine fluoride for dental caries management in
1. American Academy of Pediatric Dentistry. The use of a children and adolescents, including those with special
caries-risk assessment tool (CAT) for infants, children, health care needs. Pediatr Dent 2017;39(5):135-45.
and adolescents. Pediatr Dent 2002;24(7):15-7. 14. Slayton R, Araujo M, Guzman-Armstrong S, et al.
2. American Academy of Pediatric Dentistry. Caries-risk Evidence-based clinical practice guideline for non-
assessment and management for infants, children, and restorative management of dental caries. J Am Dent Assoc
adolescents. Pediatr Dent 2014;36(special issue):127-34. 2018;149(10):837-49.
3. American Dental Association. Guidance on caries risk 15. Wright JT, Crall JJ, Fontana M, et al. Evidence-based clinical
assessment in children, June 2018. Available at: “https:// practice guideline for the use of pit-and-fissure sealants.
www.ada.org/~/media/ADA/DQA/CRA_Report.pdf?la=en”. American Academy of Pediatric Dentistry, American
Accessed February 12, 2019. (Archived by WebCite
at: “http://www.webcitation.org/768BDwVDc”)
® Dental Association. Pediatr Dent 2016;38(5):E120-E36.
16. Vercammen KA, Frelier JM, Lawery CM, McGlone ME,
4. Fontana M. The clinical, environmental, and behavioral Ebbeling CB, Bleich SN. A systematic review of strategies
factors that foster early childhood caries: Evidence for to reduce sugar-sweetened beverage consumption among
caries risk assessment. Pediatr Dent 2015;37(3):217-25. 0-year to 5-year olds. Obesity Review 2018;19(11):
5. Cagetti MG, Bonta G, Cocco F, Lingstrom P, Strohmenger 1504-24.
L, Campus G. Are standardized caries risk assessment 17. Alaluusua S, Malmivirta R. Early plaque accumulation: A
models effective in assessing actual caries status and sign for caries risk in young children. Community Dent
future caries increment? A systematic review. BMC Oral Oral Epidemiol 1994;22(10):273-6.
Health 2018;18(1):123. 18. Ramos-Gomez F, Ng MW. Into the future: Keeping
6. Moyer V. Prevention of dental caries in children from healthy teeth caries free. Pediatric CAMBRA protocols.
birth through age 5 years: U.S. Preventive Services Task J Cal Dent Assoc 2011;39(10):723-32.
Force recommendation statement. Pediatrics 2014;133 19. Centers for Disease Control and Prevention. Recommen-
(6):1102-10. dations for using fluoride to prevent and control dental
7. Food and Drug Administration, American Dental Asso- caries in the United States. MMWR Recomm Rep 2001;
ciation, Department of Health and Human Services. 50(RR14):1-42.
Dental radiographic examinations for patient selection 20. American Academy of Pediatric Dentistry. Policy on
and limiting radiation exposure, 2012. Available at: interim therapeutic restorations. Pediatr Dent 2018;40
“https://www.ada.org/~/media/ADA/Member%20Center/ (special issue):58-9.
FIles/Dental_Radiographic_Examinations_2012.pdf ”. 21. American Academy of Pediatric Dentistry. Pediatric
Accessed February 12, 2019. (Archived by WebCite at:
“http://www.webcitation.org/768BXNww3”)
® restorative dentistry. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
8. Rotter T, Kinsman L, James E, et al. The effects of clini- Dentistry; 2019:341-53.
cal pathways on professional practice, patient outcomes, 22. Parker C. Active surveillance: Toward a new paradigm in
length of stay, and hospital costs: Cochrane systematic the management of early prostate cancer. Lancet Oncol
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3-27. 23. Ekstrand KR, Bakhshandeh A. Martignon S. Treatment
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Epidemiol 2013;41(1):1-12. 24. Ramos-Gomez FJ, Crall J, Gansky SA, Slayton RL,
10. Weyant RJ, Tracy SL, Anselmo T, et al. Topical fluoride Featherstone JDB. Caries risk assessment appropriate for
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Am Dent Assoc 2014;145(2):182-9.

BEST PRACTICES: PRESCRIBING DENTAL RADIOGRAPHS
Prescribing Dental Radiographs for Infants,

Health Care Needs
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Prescribing
2017 dental radiographs for infants, children, adolescents, and individuals
2020:248-51.
Purpose of the initial radiographic examination should not be based

The American Academy of Pediatric Dentistry (AAPD) intends upon the patient’s age, but upon each child’s individual
these recommendations to help practitioners make clinical circumstances. Radiographic screening for the purpose of
decisions concerning appropriate selection of dental radiographs detecting disease before clinical examination should not be
as part of an oral evaluation of infants, children, adolescents, performed.6 Because each patient is unique, the need for dental
and individuals with special health care needs. The recom- radiographs can be determined only after consideration of the
mendations can be used to optimize patient care, minimize patient’s medical and dental histories, completion of a thorough
radiation burden, and allocate health care resources responsibly. clinical examination, and assessment of the patient’s vulnera-
bility to environmental factors that affect oral health. AAPD’s
Methods recommendations for assessing risk for caries development in
In 1981, the Ad Hoc Committee on Pedodontic Radiology of children ages 0-5 years and ≥6 years can be found in Caries-
the American Academy of Pedodontics developed guidance risk Assessment and Management for Infants, Children, and
on radiographic examination of pediatric dental patients.1 Six Adolescents. 7 Review of prior radiographs, when available
years later, the U.S. Food and Drug Administration (FDA) from within the same practice or through record transfer, also
published recommendations2 developed by an expert dental contributes to the decision of radiographic necessity.
panel, which included a representative of the AAPD, convened Radiographs should be taken only when there is an ex-
“to reach a consensus on standardizing dental radiographic pectation that the diagnostic yield will affect patient care. The
procedures” 3. In 2002, the American Dental Association AAPD recognizes that there may be clinical circumstances
(ADA) initiated a review of that document. The AAPD, along for which a radiograph is indicated, but a diagnostic image
with other dental specialty organizations, participated in the cannot be obtained. For example, the patient may be unable to
review and revision of those guidelines. The FDA accepted cooperate or the dentist may have privileges in a health care
the revision in November 2004,4 and the AAPD endorsed it facility lacking intraoral radiographic capabilities. If radio-
the following Spring. This review includes a new search of the graphs of diagnostic quality are unobtainable, the dentist
®
PubMed /MEDLINE database using the terms: dental radiology,
dental radiographs, dental radiography, cone-beam computed
should confer with the parent to determine appropriate man-
agement techniques (e.g., preventive/restorative interventions,
tomography AND guidelines, recommendations; fields: all; advanced behavior guidance modalities, deferral, referral),
limits: within the last 10 years, humans, and English. The giving consideration to the relative risks and benefits of the
ADA Council on Scientific Affairs has published updates to various treatment options for the patient.
their recommendations for dental radiographs.5,6 The AAPD’s Because the effects of radiation exposure accumulate over
Council of Clinical Affairs has developed these best practices time, every effort must be made to minimize the patient’s
and continues to endorse the ADA/FDA’s recommendations. exposure. Good radiological practices are important in mini-
mizing or eliminating unnecessary radiation in diagnostic
Background dental imaging. Examples of good radiologic practice include:
Radiographs are valuable aids in the oral health care of infants,
children, adolescents, and individuals with special health care
needs. They are used to diagnose and monitor oral diseases, ABBREVIATIONS
AAOMR: American Academy of Oral and Maxillofacial Radiology.
evaluate dentoalveolar trauma, as well as monitor dentofacial
AAPD: American Academy of Pediatric Dentistry. ADA: American
development and the progress of therapy. The recommenda- Dental Association. CBCT: Cone-beam computed tomography.
tions in the ADA/FDA guidelines were developed to serve as FDA: U.S. Food and Drug Administration.
an adjunct to the dentist’s professional judgment. The timing

1) use of the fastest image receptor compatible with the New imaging technology (i.e., cone beam computed tom-
diagnostic task (F-speed film or digital), 2) collimation of the ography [CBCT]) has added three-dimensional capabilities
beam to the size of the receptor whenever feasible, 3) proper that have many applications in dentistry. The use of CBCT
film exposure and processing techniques, 4) use of protective has been valuable as an adjunct diagnostic tool in assessing
aprons and thyroid collars, when appropriate, and 5) limiting periapical pathosis in endodontics, oral pathology, anomalies
the number of images to the minimum necessary to obtain in the developing dentition (e.g., impacted, ectopic, or super
essential diagnostic information.6 The dentist must weigh the numerary teeth), oral maxillofacial surgery (e.g., cleft palate),
benefits of obtaining radiographs against the patient’s risk of dental and facial trauma, and orthodontic and surgical pre-
radiation exposure. paration for orthognathic surgery. The American Academy of
Table. RECOMMENDATIONS FOR PRESCRIBING DENTAL RADIOGRAPHS 6

Patient Age and Dental Developmental Stage
Type of Encounter Child with Primary Child with Transitional Adolescent with Permanent Adult, Dentate or
Dentition Dentition Dentition Partially Edentulous
(prior to eruption of first (after eruption of first (prior to eruption of third molars)
permanent tooth) permanent tooth)
New Patient* Individualized radiographic Individualized radiographic Individualized radiographic exam consisting of posterior bite-
being evaluated for oral exam consisting of selected exam consisting of posterior wings with panoramic exam or posterior bitewings and selected
diseases. periapical/occlusal views and/ bitewings with panoramic periapical images. A full mouth intraoral radiographic exam is
or posterior bitewings if exam or posterior bitewings preferred when the patient has clinical evidence of generalized
proximal surfaces cannot be and selected periapical oral disease or a history of extensive dental treatment.
visualized or probed. Patients images.
without evidence of disease
and with open proximal con-
tacts may not require a radio-
graphic exam at this time.
Recall Patient* Posterior bitewing exam at 6-12 month intervals if proximal surfaces cannot be examined visually or Posterior bitewing exam at
with clinical caries or at with a probe. 6-18 month intervals.
increased risk for caries.**
Recall Patient* with no Posterior bitewing exam at 12-24 month intervals if proximal Posterior bitewing exam at 18-36 Posterior bitewing exam at
clinical caries and not at surfaces cannot be examined visually or with a probe. month intervals. 24-36 month intervals.
increased risk for caries.**
Patient (New and Recall) Clinical judgment as to need for and type of radiographic Clinical judgment as to need for Usually not indicated for
for monitoring of dento- images for evaluation and/or monitoring of dentofacial and type of radiographic images monitoring of growth and
facial growth and develop growth and development or assessmentof dental and skeletal for evaluation and/or monitor- development. Clinical
ment, and/or assessment relationships. ing of dentofacial growth and judgment as to the need
of dental/skeletal development, or assessment of for and type of radio-
relationships. dental and skeletal relationships. graphic image for evalua-
Panoramic or periapical exam to tion of dental and skeletal
assess developing third molars. relationships.
Patient with other circum-

stances including, but not
limited to, proposed or
existing implants, other
dental and craniofacial Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring in these conditions.
pathoses, restorative/
endodontic needs, treated
periodontal disease and
caries remineralization.
* &OLQLFDOVLWXDWLRQVIRUZKLFKUDGLRJUDSKVPD\EHLQGLFDWHGLQFOXGHEXWDUHQRWOLPLWHGWR
A. Positive Historical Findings B. Positive Clinical Signs/Symptoms
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8
Copyright © 2012 American Dental Association. All rights reserved. Reprinted with permission.

Oral and Maxillofacial Radiology (AAOMR) has published 4. American Dental Association, U.S. Department of Health
position statements which summarize the potential benefits and Humans Services. The selection of patients for dental
and risks of maxillofacial CBCT use in orthodontic and radiographic examinations—2004. Available at: “https:
endodontic diagnosis, treatment, and outcomes and provides //www.fda.gov/downloads/Radiation-EmittingProducts/
clinical guidance to dental practitioners. 10,11 The AAOMR’s RadiationEmittingProductsandProcedures/Medical
position statements support and affirm the position of the Imaging/MedicalX-Rays/ucm116505.pdf ”. Accessed
ADA Council on Scientific Affairs in that the selection of
CBCT imaging must be justified based on individual need.10-12
®
November 6, 2016. (Archived by WebCite at:“http://
www.webcitation.org/6owR38t1A”)
Because this technology has potential to produce vast amounts 5. American Dental Association Council on Scientific
of data and imaging information beyond initial intentions, it Affairs. The use of dental radiographs: Update and
is important to interpret all information obtained, including recommendations. J Am Dent Assoc 2006;137(9):
that which may be beyond the immediate diagnostic needs 1304-12.
or abilities of the practitioner. 6. American Dental Association Council on Scientific
Affairs, U.S. Department of Health and Humans Services
Recommendations Public Health Service Food and Drug Administration.
The recommendations of the ADA/FDA guidelines are Dental Radiographic Examinations: Recommendations
contained within the accompanying Table. “These recom- for Patient Selection and Limiting Radiation Exposure.
mendations are subject to clinical judgment and may not Chicago, Ill.; 2012:5-7. Available at: “http://www.ada.
apply to every patient. They are to be used by dentists only org/~/media/ADA/Publications/ADA%20News/Files/
after reviewing the patient’s health history and completing Dental_Radiographic_Examinations_2012.pdf ”. Accessed
a clinical examination. Even though radiation exposure from
dental radiographs is low, once a decision to obtain radio-
®
November 6, 2016. (Archived by WebCite at: “http:
//www.webcitation.org/6tv6SjRaF”)
graphs is made it is the dentist’s responsibility to follow the 7. American Academy Pediatric Dentistry. Caries-risk
as low as reasonably achievable (ALARA principle) to minimize assessment and management for infants, children, and
the patient’s exposure.”6 adolescents. Pediatr Dent 2017;39(6):197-204.
Intraoral imaging should be maintained as the standard 8. American Dental Association. Caries risk form (Ages 0-6
diagnostic tool. The use of CBCT should be considered when years). ADA Resources: ADA Caries Risk Assessment
conventional radiographs are inadequate to complete diagnosis Forms. Caries Risk Assessment and Management. Chi-
and treatment planning and the potential benefits outweigh cago, Ill. Available at: “http://www.ada.org/~/media/
the risk of additional radiation dose. It must not be routinely ADA/Member%20Center/FIles/topics_caries_under6.
prescribed for diagnosis or screening purposes in the absence pdf?la=en”. Accessed September 27, 2016. (Archived by
of clinical indication. Basic principles and guidelines for the
use of CBCT include: 1) use of appropriate image size or field
®
WebCite at: “http://www.webcitation.org/6tvAwgomN”)
9. American Dental Association. Caries risk form (Over 6
of view, 2) assess the radiation dose risk, 3) minimize patient years). ADA Resources: ADA Caries Risk Assessment
radiation exposure and, 4) maintain professional competency Forms. Caries Risk Assessment and Management. Chi-
in performing and interpreting CBCT studies. 10-13 When cago, Ill. Available at: “http://www.ada.org/~/media/
using CBCT, the resulting imaging is required to be supple- ADA_Foundation/GKAS/Files/topics_caries_educational_
mented with a written report placed in the patient’s records over6.pdf?la=en”. Accessed September 27, 2016. (Archived
that includes full interpretation of the findings. ®
by WebCite at: “http://www.webcitation.org/6tv
B0CMMs”)
References 10. American Academy of Oral and Maxillofacial Radiology.
1. American Academy of Pedodontics. Dental radiographs Clinical recommendations regarding use of cone beam
in children. Chicago, Ill.: American Academy Pediatric computed tomography in orthodontics. Position state-
Dentistry Reference Manual 1991-1992. American ment by the American Academy of Oral and Maxillo-
Academy of Pediatric Dentistry; 1991:27-8. facial Radiology. Oral Surg Oral Med Oral Pathol Oral
2. Joseph LP. The Selection of Patients for X-ray Exam- Radiol 2013;116(2):238-57. Erratum in Oral Surg Oral
inations: Dental Radiographic Examinations. Rockville, Med Oral Pathol Oral Radiol 2013;116(5):661.
Md.: The Dental Radiographic Patient Selection Criteria 11. Special Committee to Revise the Joint AAE/AAOMR
Panel, U.S. Department of Health and Humans Services, Position Statement on use of CBCT in Endodontics. AAE
Center for Devices and Radiological Health; 1987. HHS and AAOMR joint position statement: Use of cone
Publication No. FDA 88-8273. beam computed tomography in endodontics 2015
3. American Academy Pediatric Dentistry. Guidelines for Update. Oral Surg Oral Med Oral Pathol Oral Radiol
prescribing dental radiographs. Pediatr Dent 1995;17(6): 2015;120(4):508-12.
66-7.

12. American Dental Association Council on Scientific 13. SEDENTEXCT Project (2008-2011). Radiation pro-
Affairs. The use of cone-beam computed tomography tection: Cone beam CT for dental and maxillofacial
in dentistry. An advisory statement from the American radiology. Evidence-based guidelines. Available at: “https:
Dental Association Council on Clinical Affairs. J Am //ec.europa.eu/energy/sites/ener/files/documents/172.pdf ”.
Dent Assoc 2012;143(8):899-902. Accessed November 6, 2016. (Archived by WebCite
at: “http://www.webcitation.org/6owRWlv64”)
®

BEST PRACTICES: PERINATAL AND INFANT OHC
Perinatal and Infant Oral Health Care

Latest Revision How to Cite: American Academy of Pediatric Dentistry. Perinatal
2016 and infant oral health care. The Reference Manual of Pediatric
2020:252-6.
Purpose ECC and the more severe form of ECC (i.e., s-ECC)
The American Academy of Pediatric Dentistry (AAPD) begin soon after tooth eruption, developing on all surfaces of
recognizes that perinatal and infant oral health are the foun- primary teeth, progressing rapidly, and having a lasting detri-
dations upon which preventive education and dental care mental impact on the dentition.4,5 This disease affects the
must be built to enhance the opportunity for a child to have general population, but is 32 times more likely to occur in
a lifetime free from preventable oral disease. Recognizing that infants who are of low socioeconomic status, who consume a
dentists, physicians, allied health professionals, and community diet high in sugar, and whose mothers have a low education
organizations must be involved as partners to achieve this level.6-8 The consequences of ECC often include higher risk
goal, the AAPD proposes guidelines for perinatal and infant of new carious lesions in both the primary and permanent
oral health care, including caries risk assessment, anticipatory dentitions5,9,10 hospitalizations and emergency room visits,11,12
guidance, preventive strategies, and therapeutic interventions, high treatment costs,13 loss of school days,14 diminished ability
to be followed by the stakeholders in pediatric oral health. to learn,15 and reduced oral health-related quality of life.16
It has been reported that 89 percent of children age one
Method year had an office-based physician visit, compared with only
Recommendations on perinatal and infant oral health care 1.5 percent who had a dental office visit.17 In a recent study,
were developed by the Infant Oral Health Subcommittee of 99 percent of Medicaid-enrolled children had well baby visits
the Clinical Affairs Committee and adopted in 1986. The before age one, whereas only two percent had a dental visit.18
Guideline on Perinatal Oral Health Care was originally devel- Since medical health care professionals see new mothers and
oped by the Infant Oral Health Subcommittee of the Council infants earlier and more often than dentists, it is essential that
on Clinical Affairs and adopted in 2009. This document is they be aware of the multifactorial etiology and associated risk
a merger and an update of the previous versions, revised by factors of ECC, give appropriate counseling regarding ECC
the Council of Clinical Affairs in 2014 and 2011 respectively. prevention to pregnant women and caregivers, and facilitate
This revision included a search of the PubMed /MEDLINE ®
database using the terms: infant oral health, infantoral health
the establishment of a dental home.19
Because restorative care to treat ECC often requires the
care, early childhood caries, perinatal, perinatal oral health, and use of sedation and general anesthesia with associated high
early childhood caries prevention; fields: all; limits: within the costs and possible health risks,20 and because there is high
last 10 years, humans, English, and clinical trials. Papers for recurrence of lesions subsequent to the procedures,21 there is
review were chosen from the resultant list of articles and from now more emphasis on prevention and arrestment of the disease
references within selected articles and hand searches of the processes to manage ECC. Approaches include methods that
literature. When data did not appear sufficient or were incon- have been referred to as (1) chronic disease management, which
clusive, recommendations were based upon expert and/or includes parent engagement to facilitate preventive measures
consensus opinion by experienced researchers and clinicians. and temporary restorations to postpone advanced restorative
care,22 (2) active surveillance, which emphasizes careful moni-
Background toring of caries progression and establishment of a prevention
Dental caries, consequences, and management program in children with incipient lesions,23 and (3) interim
The Centers for Disease Control and Prevention reports that therapeutic restorations (ITR) that temporarily restore teeth in
dental caries is the most prevalent chronic disease in our na- young children until a time when traditional cavity preparation
tion’s children.1 More than 28 percent of children have caries and restoration is possible.24
by the time they reach kindergarten.2 Epidemiologic data
from a 2011-2012 national survey clearly indicate that early
childhood caries (ECC) remains highly prevalent in poor and
near poor U.S. preschool children. For the overall population
ABBREVIATIONS
of preschool children, the prevalence of ECC, as measured AAPD: American Academy Pediatric Dentistry. ECC: Early child-
by decayed and filled tooth surfaces (dfs), is unchanged from hood caries. dfs: Decayed and filled tooth surfaces. ITR: Interim
previous surveys, but the filled component (fs) has greatly therapeutic restorations. MI: Motivational interviewing.
increased indicating that more treatment is being provided.3

The perinatal period and anticipatory guidance for the prevention and control of caries is documented to be
The perinatal period is defined as the period around the time both safe and effective.46,47 Optimal exposure to fluoride is
of birth, beginning with the completion of the 20th to 28th important to all dentate infants and children.48 Systemically-
week of gestation and ending one to four weeks after birth. administered fluoride should be considered for all children
The perinatal period plays a crucial role for the well-being who do not receive fluoride by consuming fluoridated water
of pregnant women.25 Also, it is essential for the health and (less than 0.7 part per million) in after determining all other
well-being of their newborn children. Yet, many women do dietary sources of fluoride exposure.47 The correct amount of
not seek dental care during their pregnancy, and those who fluoridated toothpaste should be used twice daily by all children
do often confront unwillingness of dentists to provide care.26-29 regardless of risk. No more than a smear or rice-sized amount
Many expectant mothers are unaware of the implications of of fluoridated toothpaste should be used for children under
poor oral health for their pregnancy and/or their unborn age three.49 Professionally-applied fluoride varnish should be
child.28,30,31 considered for children at risk for caries.23
Identifying mothers with high levels of dental caries and Practitioners should counsel parents that high frequency
poor oral health and educating them on the importance of consumption of sugars by bottle-feeding, sippy cup use, or
their own oral health and the future health of their unborn between meal consumption of sugars increases the risk of
child can help change their trajectory of oral health. Timely caries.50 The American Academy of Pediatrics has recom-
delivery of educational information and preventive therapies mended children one through six years of age consume no
to these parents may reduce the incidence of ECC, prevent more than four to six ounces of 100 percent fruit juice per
the need for dental rehabilitation, and improve the oral health day, from a cup (i.e., not a bottle or covered cup).51 Epidemio-
of their children.32-34 Physicians, nurses, and other health care logical research shows that human milk and breast-feeding of
professionals are far more likely to see expectant or new moth- infants provide general health, nutritional, developmental, and
ers and their infants than are dentists. Therefore, it is essential psychological advantages while significantly decreasing risk for
that these providers be aware of oral anomalies and associated a large number of acute and chronic diseases.52 Frequent night-
risk factors of dental caries in order to make appropriate deci- time bottle-feeding with milk and ad libitum breast-feeding
sions regarding timely and effective interventions for pregnant are associated, but not consistently implicated, with ECC.53
women and facilitate the establishment of a dental home for Parents also should be counseled that prolonged non-
the child.35-37 nutritive oral habits may contribute to deleterious changes in
Caries-risk assessment for infants determines the patient’s the child’s occlusion and facial development and that there
relative risk for dental disease and allows for the institution of are serious health consequences of tobacco use and exposure to
appropriate strategies as the primary dentition begins to erupt. secondhand smoke.38 Furthermore, practitioners should provide
Its goal is to prevent disease by identifying and minimizing age-appropriate injury prevention counseling for oro-facial
causative factors (e.g., dietary habits, plaque accumulation, trauma.38
lack of topical or systemic fluoride, frequent use of sugar
containing medications) and optimizing protective factors Management of perinatal and infant oral health
(e.g., fluoride exposure, oral hygiene practices, sealants).38 Oral health care for pregnant and lactating women. The peri-
Caries-risk assessment also allows health care professionals to natal period is an opportune time to educate and perform
identify and refer high caries-risk patients for appropriate dental treatment on expectant mothers.54-56 Pregnancy care
dental management.23 visits provide a teachable moment for physicians, dentists, and
Even the most judiciously designed and implemented nurses to educate women about the following:
caries-risk assessment can fail to identify all infants at risk • diet including the adequate quality and quantity of
for developing ECC. The early establishment of a dental nutrients for the mother-to-be and the unborn child.
home, including ECC prevention and management, is the This education also should include information regard-
ideal approach to infant oral health care.39,40 The inclusion of ing the caries process and food cravings that may increase
oral health education into the curriculum of medical, dental, the mother’s caries risk.
nursing, and allied health professional programs can facilitate • comprehensive oral examination, dental prophylaxis, and
the acceptance of the age one dental visit.41,42 Recent studies, treatment during pregnancy. Dental treatment during
noting that a majority of pediatricians and general dentists pregnancy, including dental radiographs with proper
were not advising patients to see a dentist by one year of shielding and local anesthetic, is safe in all trimesters
age, point to the need for increased infant oral health care and optimal in the second trimester. Due to possible
education in the medical and dental communities.43-45 patient discomfort, elective treatment sometimes may
Anticipatory guidance to reduce the risk of dental caries be deferred until after delivery.
should include counseling regarding brushing of child’s • proper oral hygiene, using a fluoridated toothpaste,
teeth twice daily with the appropriate amount of fluoridated chewing sugar-free gum, and eating small amounts of
toothpaste, diet analysis, and counseling to reduce the con- nutritious food throughout the day to help minimize
sumption of sugar-containing beverages.38 The use of fluoride their caries risk.

• continued breast-feeding along with complementary References

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51. American Academy of Pediatrics Committee on Nutri- or mouth. Available at: “http://www.fda.gov/drugs/
tion. Policy statement: The use and misuse of fruit juices drugsafety/ucm250024.htm”. Accessed July 1, 2016.
in pediatrics. Pediatrics 2001;107(5):1210-3. Reaffirmed 60. American Academy of Pediatric Dentistry. Guideline on
October, 2006. management considerations for pediatric oral surgery
52. American Academy of Pediatrics. Policy statement: and oral pathology. Pediatr Dent 2016;38(special issue):
Breastfeeding and the use of human milk. Pediatrics 2012; 315-24.
129(3):e827-41. 61. Douglass JM, Clark MB. Integrating oral health into
53. Reisine S, Douglass JM. Psychosocial and behavioral overall health care to prevent early childhood caries:
issues in early childhood caries. Community Dent Oral Need, evidence, and solutions. Pediatr Dent 2015;37(3):
Epidemiol 1998;26(suppl):32-44. 266-74.
54. Silk H, Douglass AB, Douglass JM, Silk L. Oral health
during pregnancy. Am Fam Physician 2008;77(8):
1139-44.

BEST PRACTICES: ADOLESCENT OHC
Adolescent Oral Health Care

Latest Revision How to Cite: American Academy of Pediatric Dentistry. Adolescent
2020 oral health care. The Reference Manual of Pediatric Dentistry. Chicago,
Purpose Treatment of the adolescent patient can be multi-faceted

The American Academy of Pediatric Dentistry (AAPD) and complex. Accurate, comprehensive, and up-to-date medi-
recognizes that the adolescent patient has unique needs. This cal, dental, and social histories are necessary for correct
best practice addresses these unique needs and proposes general diagnosis and effective treatment planning. Familiarity with
recommendations for their management. This best practice the patient’s medical history is essential for decreasing the
serves as a summary document; more detailed information risk of aggravating a medical condition while rendering dental
regarding these topics is provided in referenced AAPD oral care. In some cases, the parent or family members are unaware
health policies and clinical practice guidelines. of certain conditions affecting/facing the adolescent patient.
The dental practitioner needs to assure the adolescent patient
Methods of trust and confidentiality in certain situations. If the parent
This best practice was developed by the Clinical Affairs Com- is unable to provide adequate details regarding a patient’s
mittee and adopted in 1986.1 This document by the Council medical history, consultation with the medical health care
on Clinical Affairs is a revision of the previous version, last provider may be indicated.12
revised in 2015.2 The update includes an electronic search There is a growing number of adolescents who experi-
using the term adolescent combined with: dental, gingivitis, ence gender dysphoria and may be considering or undergoing
oral piercing, sealants, oral health, caries, tobacco use, dental gender identity-related medical and health care services.13,14
trauma, orofacial trauma, periodontal, dental esthetics, smoke- The current prevalence of transgender and non-conforming
less tobacco, nutrition, and diet; fields: all; limits: humans, youth is about two percent. 15 Health history forms should
English, clinical trials. The reviewers agreed upon the inclusion allow youth to provide information on gender, legal and pre-
of 105 electronic and hand searched articles that met the ferred name, and preferred pronouns.16 Dental office staff
defined criteria. When data did not appear sufficient or were should determine preferences, and terminology used should be
inconclusive, recommendations were based upon expert and/ consistent by all staff. Transgender and gender diverse youth
or consensus opinion by experienced researchers and clinicians. may be at increased risk for eating disorders or substance use
disorders.17,18 Special attention should be given to identifying
Background dental and systemic conditions that may be linked to such
Adolescence refers to the period of accelerated biological disorders.
growth, changes, and social role transitions that bridges the
gap from childhood to adulthood.3 The definition of adoles- Recommendations
cence has changed due to accelerated onset of puberty, This best practice addresses some of the special needs within the
delayed timing of role transitions (e.g., completion of educa- adolescent population and proposes general recommendations
tion, marriage, parenthood), and the effect of unprecedented for their management.
social forces such as social media.3 Rather than age 10-19
years, it has been defined as the period between 10 and up Caries
to 24 years. 3 The American Academy of Pediatrics divides Adolescence marks a period of significant caries activity for
adolescence into three age groups including early (ages 11-14), many individuals. Research suggests that the overall caries
middle (ages 15-17), and late (ages 18-21).4 rate is declining, yet remains highest during adolescence.19
The adolescent patient is recognized as having distinctive Immature permanent tooth enamel,20 a total increase in sus-
needs5 due to: (1) a potentially high caries rate; (2) a tendency ceptible tooth surfaces, and environmental factors such as diet,
for poor oral hygiene, nutritional habits, and routine oral independence to seek care or avoid it, a low priority for oral
health care access; (3) increased risk for periodontal disease
and traumatic injury; (4) an increased esthetic desire and
awareness; (5) increased risk for periodontal disease and trau-
ABBREVIATIONS
matic injury; (6) dental phobia; (7) potential use of tobacco,
AAPD: American Academy Pediatric Dentistry. HPV: Human papil-
nicotine, alcohol, and other recreational drugs; (8) desire for loma virus. NaF: Sodium fluoride OHRQoL: Oral health-related
oral piercings; (9) increased risk of pregnancy or sexually quality of life. SHCN: Special health care needs. TMJ: Temporo-
transmitted infections; (10) eating disorders; and (11) unique mandibular joint.
social and psychological needs.6-11

hygiene, and additional social factors also may contribute to 2. Professional removal of plaque and calculus is recom-
the upward slope of caries during adolescence.21-25 Untreated mended highly for the adolescent, with the frequency
dental caries and missing teeth have been shown to have a neg- of such intervention based on the individual’s assessed
ative impact on oral health-related quality of life (OHRQoL), risk for caries/periodontal disease as determined by the
however, restored teeth were not associated with worse patient’s dental provider.31,32
OHRQoL.26 It is important for the dental provider to empha-
size the positive effects that fluoridation, professional topical Diet management: Many adolescents are exposed to and con-
fluoride treatment, routine professional care, patient education, sume high quantities of refined carbohydrates and acid-
and personal hygiene can have in counteracting the changing containing beverages in the form of soda, high-energy sports
pattern of caries in the adolescent population.6-8 drinks, and junk food and with introduction of coffee.8,22,23,25,33
The adolescent can benefit from diet analysis and modification.
Management of caries Recommendation: Diet analysis, along with professionally-
Primary prevention determined recommendations for maximal general and dental
Fluoride: Fluoridation has proven to be safe and highly effective health, should be part of an adolescent’s dental health man-
in prevention and control of caries.27 The adolescent can benefit agement.34
from fluoride throughout the teenage years and into early
adulthood.8 Although the systemic benefit of fluoride incor- Sealants: Sealant placement is an effective caries-preventive
poration into developing enamel is not considered necessary technique that should be considered on an individual basis.
past 16 years of age, topical benefits can be obtained through Sealants have been recommended for any tooth, primary or
optimally-fluoridated water, professionally-applied and pre- permanent, that is judged to be at risk for pit and fissure car-
scribed compounds, and fluoridated dentifrices.28,29 ies.7,23,36-38 Caries risk may increase due to changes in patient
Recommendation: The adolescent should receive maxi- habits, oral microflora, or physical condition, and unsealed
mum fluoride benefit dependent on risk assessment:29,30 teeth subsequently might benefit from sealant applications.37
• brushing teeth twice a day with a fluoridated dentifrice Recommendations: Adolescents at risk for caries should
is recommended to provide continuing topical benefits.27 have sealants placed. An individual’s caries risk may change
• professionally-applied fluoride treatments should be over time; periodic reassessment for sealant need is indicated
based on the individual patient’s caries-risk assessment, as throughout adolescence.37
determined by the patient’s dental provider.27,29
• home-applied prescription strength topical fluoride prod- Secondary prevention
ucts (e.g., 0.4 percent stannous fluoride gel, 0.5 percent Professional preventive care: Professional preventive dental
fluoride gel or paste, 0.2 percent sodium fluoride [NaF] care, on a routine basis, may prevent oral disease or disclose
rinse) may be used when indicated by an individual’s existing disease in its early stages. The adolescent patient
caries pattern or caries risk status.27 whose oral health has not been monitored routinely by a
• systemic fluoride intake via optimal fluoridation of dentist may have advanced caries, periodontal disease, or other
drinking water or professionally-prescribed supplements oral involvement urgently in need of professional evaluation
is recommended to 16 years of age. Supplements should and extensive treatment.
be given only after all other sources of fluoride have been Recommendations:
evaluated.27 1. Timing of periodic oral examinations should take into
consideration the individual’s needs and risk indicators
Oral hygiene: Adolescence can be a time of heightened caries to determine the most cost-effective, disease-preventive
activity and periodontal disease due to an increased intake of benefit to the adolescent.30
cariogenic substances and inattention to oral hygiene proce- 2. Initial and periodic radiographic examination should be
dures.21 Adolescents become more independent and tooth- part of a clinical evaluation. The type, number, and fre-
brushing may become less of a priority. Adolescent patients quency of radiographs should be determined only after
need encouragement and motivation to brush with fluoridated an oral examination and history taking. Previously ex-
toothpaste and floss regularly. Discussions regarding oral posed radiographs should be available, whenever possible,
hygiene can highlight the benefit of the topical effect of for comparison. Currently accepted recommendations for
fluoride, removal of plaque from tooth surfaces, and also radiographic exposures (i.e., appropriate films based upon
decrease halitosis and improve esthetics.8,31 medical history, caries risk, history of periodontal disease,
Recommendations: and growth and development assessments) should be
1. Adolescents should be educated and motivated to main- followed.38
tain personal oral hygiene through daily plaque removal,
including flossing, with the frequency and technique Restorative dentistry: There is data to suggest arrest or reversal
based on the individual’s disease pattern and oral hygiene of noncavitated caries lesions using sealants, five percent NaF
needs.31 varnish, 1.23 percent acidulated phosphate fluoride (APF) gel,

and 5000 parts per million fluoride toothpaste for specific sites oral hygiene and regular professional intervention can help
in primary and permanent teeth and, in advanced cavitated minimize occurrence of these conditions and prevent irre-
carious lesions on primary teeth, the use of 38 percent silver versible damage.
diamine fluoride (SDF).39 In cases where remineralization of Recommendations: The adolescent will benefit from an in-
non-cavitated, demineralized tooth surfaces is not successful, as dividualized preventive dental health program, which includes
demonstrated by progression of carious lesions, dental restora- the following items aimed specifically at periodontal health:
tions are necessary. Preservation of tooth structure, esthetics, • patient education emphasizing the etiology, character-
and each individual patient’s needs must be considered when istics, and prevention of periodontal diseases as well as
selecting a restorative material.40 Molars with extensive caries self-hygiene skills.45,48,49
or malformed, hypoplastic or hypomineralized enamel for • a personal, age-appropriate oral hygiene program in-
which traditional amalgam or composite resin restorations are cluding plaque removal, oral health self-assessment, and
not feasible may require full coverage restorations.37 Small diet. Sulcular brushing and flossing should be included
noncavitated interproximal carious lesions and facial post in plaque removal, and frequent follow-up to determine
orthodontic white spot lesions may be treated by resin adequacy of plaque removal and improvement of gingival
infiltration.37,41,42 health should be considered.48-50
Recommendation: Each adolescent patient and restoration • periodontal assessment during initial and routine dental
must be evaluated on an individual basis. Preservation of non- examinations with professional intervention, the fre-
carious tooth structure is desirable. Referral should be made quency of which should be based on individual needs
when treatment needs are beyond the treating dentist’s scope and should include evaluation of personal oral hygiene
of practice.37 success, periodontal status, and potential complicating
factors such as malocclusion, medical/systemic conditions
Periodontal diseases or habits that predispose to periodontal disease. Compre-
Adolescence can be a critical period for the human being’s hensive periodontal examination includes an assessment
periodontal status. Epidemiologic and immunologic data sug- of gingival topography; probing depth; recession; attach-
gest that irreversible tissue damage from periodontal disease ment levels; bleeding on probing; suppuration; furcation;
begins in late adolescence and early adulthood.10,43 Gingival presence and degree of plaque, calculus, and gingival
disease becomes prevalent in adolescence.44,45 Dental caries, inflammation; mobility of teeth; periodontal charting;
mouthbreathing, crowding, and eruption of teeth predispose and radiographic periodontal diagnosis should be a
adolescents to gingivitis.44 Hormonal changes during adoles- consideration when caring for the adolescent. The extent
cence are suspected to be a cause of the increased prevalence45, and nature of the periodontal evaluation should be
with studies suggesting that the increase in sex hormones determined professionally on an individual basis. Those
during puberty affects the composition of the subgingival patients with progressive periodontal disease should be
microflora by modifying the gingival inflammatory response referred when the treatment needs are beyond the treating
and causing exaggerated gingival inflammation, even in the dentist’s scope of practice.44,45,48,49
presence of a small amount of plaque.44 Other studies suggest • appropriate evaluation for procedures to facilitate or-
circulating sex hormones may alter capillary permeability and thodontic treatment including, but not limited to, tooth
increase fluid accumulation in the gingival tissues, and this exposure, frenectomy, fiberotomy, gingival augmentation,
inflammatory gingivitis is believed to be transient as the body and implant placement.45
accommodates to the ongoing presence of the sex hormones.46
Conditions affecting the adolescent include, but are not Occlusal considerations
limited to, dental plaque biofilm gingivitis, non-dental Malocclusion can be a significant treatment need in the adoles-
plaque-induced gingival disease, periodontitis (including cent population as both environmental and/or genetic factors
chronic and aggressive forms), necrotizing periodontitis, peri- come into play. Although the genetic basis of much maloc-
odontitis as a manifestation of systemic disease, periodontal clusion makes it unpreventable, numerous methods exist to
abscess, endodontic-periodontal lesions, mucogingival deformi- treat the occlusal disharmonies, temporomandibular joint
ties (i.e., gingival recession), occlusal trauma, and peri-implant dysfunction, periodontal disease, and disfiguration which may
diseases.44,45 The severity of periodontal conditions are assessed be associated with malocclusion. Within the area of occlusal
by clinical and radiographic examination and can be further problems are several tooth/jaw-related discrepancies that can
characterized by staging and grading the clinical presentation.47 affect the adolescent. Third molar malposition and temporo-
Early diagnosis of periodontal disease in children is important, mandibular disorders require special attention to avoid
especially when there are systemic risk factors (e.g., poorly- long-term problems. Congenitally missing teeth present complex
controlled diabetes, leukemia, smoking, malnutrition). Refer problems for the adolescent and often require combined
to the AAPD’s Best Practice on the Classification of Periodontal orthodontic, restorative, and prosthodontic care for satisfactory
Diseases in Infants, Children, Adolescents and Individuals with resolution.
Special Health Care Needs for further information.44 Personal

Malocclusion: Any tooth/jaw positional problems that present age; growth potential; orthodontic, periodontal, and oral
significant esthetic, functional, physiologic, or emotional dys- surgical needs) must be taken into consideration.56,62-64
function are potential difficulties for the adolescent. These can Recommendations: Evaluation for patients who are
include single or multiple tooth malpositions, tooth/jaw size congenitally missing permanent teeth should include both
discrepancies, and craniofacial disfigurements. Malocclusion immediate and long-term management. Referral should be
can affect the oral health quality of life for adolescents. Ado- made when the treatment needs are beyond the treating
lescents with Class II and III malocclusions or anterior overjet dentist’s scope of practice. Due to the complexity of the
greater than six millimeters reported a significant impact on growing adolescent, a team approach may be indicated.62,65
their oral health related quality of life.51-55
Recommendations: Ectopic eruption: Abnormal eruption patterns of the adoles-
1. Malposition of teeth, malrelationship of teeth to jaws, cent’s permanent teeth can contribute to root resorption, bone
tooth/jaw size discrepancy, skeletal malrelationship, or loss, gingival defects, space loss, and esthetic concerns. Early
craniofacial malformations or disfigurement that presents diagnosis and treatment of ectopically erupting teeth can re-
functional, esthetic, physiologic, or emotional problems sult in a healthier and more esthetic dentition. Prevention and
for the adolescent should be referred for evaluation when treatment may include extraction of deciduous teeth, surgical
the treatment needs are beyond the treating dentist’s scope intervention, and/or endodontic, orthodontic, periodontal,
of practice. and/or restorative care.66-68
2. Treatment of malocclusion by a dentist should be based Recommendations: The dentist should be proactive in diag-
on professional diagnosis, available treatment options, nosing and treating ectopic eruption and impacted teeth in
patient motivation and readiness, and other factors to the young adolescent.57 Early diagnosis, including appropriate
maximize progress.56 Optimal oral hygiene and routine radiographic examination,38 is important. Referral should be
dental examinations are important to prevent deminer- made when the treatment needs are beyond the treating den-
alization during orthodontic treatment. tist’s scope of practice.65
Third molars: Third molars can present acute and chronic Traumatic injuries
problems for the adolescent. Impaction or malposition leading Epidemiological studies have shown up to 25 percent of adol-
to such problems as pericoronitis, caries, cysts, or periodontal escents and adults experienced dental trauma, with most of
problems merits evaluation for removal.57-59 The role of the these injuries involving maxillary central incisors from falls,
third molar as a functional tooth also should be considered. collisions, playing sports, accidents, violence, or recreational
Recommendations: Evaluation of third molars, including activities.69-71 The prevalence of injuries reported from studies
radiographic diagnostic aids, should be an integral part of the around the world shows a wide range from six percent to 59
dental examination of the adolescent.31 Refer to the AAPD’s percent, depending on the country and type of injury.70 Dental
Best Practices on Management Considerations for Pediatric Oral traumatic injuries are associated mostly commonly with falls
Surgery and Oral Pathology.57 Referral should be made if treat- or collisions, and males are more frequently injured across all
ment needs are beyond the treating dentist’s scope of practice. age groups.69 All sporting activities have an associated risk of
orofacial injuries due to falls, collisions, and contact with hard
Temporomandibular joint (TMJ) problems: Disorders of the surfaces.72 The administrators of youth, high school, and col-
TMJ can occur at any age, but symptoms appear more prev- lege organized sports have demonstrated that dental and facial
alent in adolescence.60,61 A recent study reported that adolescent injuries can be reduced significantly by introducing mandatory
females had more TMJ disorders than males.52 protective equipment such as face guards and mouthguards.73
Recommendations: Evaluation of the TMJ and related Additionally, youth participating in leisure activities such as
structures should be a part of the examination of the adoles- skateboarding, roller skating, trampolining, and bicycling also
cent. An adolescent comprehensive dental examination should benefit from appropriate use of mouthguards and protective
incorporate a screening evaluation of the TMJ and surrounding equipment.8,74,75 Long-term sequelae of traumatic injuries
area to include a screening history for symptoms, clinical can affect well-being, speech, need for complex care, and oral
examination and evaluation of jaw movements and, if health-related quality of life.8
indicated, radiographic imaging. Referral should be made Recommendations: Timely management of traumatic dental
when the diagnostic and/or treatment needs are beyond the injuries is very important. There is a need for greater aware-
treating dentist’s scope of practice.57,60,61 ness of and education regarding the importance of timely
management of dental trauma.69 Dentists should introduce a
Congenitally missing teeth: The impact of a congenitally miss- comprehensive trauma prevention program to help reduce the
ing permanent tooth on the developing dentition can be incidence of traumatic injury to the adolescent dentition. This
significant.62 When treating adolescent patients who are con- prevention plan should consider assessment of the patient’s
genitally missing teeth, many factors (e.g., esthetics; patient sport or activity, including level and frequency of activity.73

Once this information is acquired, recommendation and present, referral should be made if the treatment needs are
fabrication of an age-appropriate, sport-specific, and properly- beyond the treating dentist’s scope of practice. This is further
fitted mouthguard/faceguard can be initiated.73 Players should discussed in the AAPD’s policies on tobacco use, nicotine
be warned about altering the protective equipment that will delivery systems, and substance abuse.87-89
disrupt the fit of the appliance. In addition, players and
parents must be informed that injury may occur even with Oral piercing: Intraoral and perioral piercing can have local
properly-fitted protective equipment.73 and systemic adverse effects.92,93 Risks include, but are not
limited to, pain, bleeding, swelling, hematoma, delayed healing,
Additional considerations in oral/health care of the adolescent nerve damage, abscess, blood-borne infections (hepatitis B or
The adolescent can present particular psychosocial character- C, human immunodeficiency virus [HIV], Epstein-Barr virus
istics that impact the health status of the oral cavity, care [EBV], tetanus, tuberculosis), endocarditis, metal hypersensi-
seeking, and compliance. The self-concept development pro- tivity, choking from loose jewelry, enamel fractures, gingival
cess, emergence of independence, and the influence of peers trauma, periodontal recession, speech impediment, and swal-
are just a few of the psychodynamic factors impacting dental lowing difficulties or aspiration.8,93-95
health during this period.6,9,28 Recommendations: Piercing and the use of jewelry on
intraoral and perioral tissues should be discouraged due to
Esthetic concerns: Desire to improve esthetics of the dentition potential for pathologic conditions and sequelae.93 Prevention
by tooth whitening and removal of stained areas or defects can of complications begins with oral health education regarding
be a concern of the adolescent. Indications for the appropriate these adverse effects.95
use of tooth-whitening methods and products are dependent
upon correct diagnosis and consideration of eruption pattern Pregnancy: The pregnant adolescent can be affected by
of the permanent dentiton.76 The dentist must determine the physiological changes to the oral cavity (e.g., gingivitis,
appropriate mode of treatment. Use of bleaching agents, pregnancy-associated dry mouth, pyogenic granuloma).96
microabrasion, placement of an esthetic restoration, or a com- Recommendations: Proper screening for pregnancy is part
bination of treatments all can be considered.77,78 of care of the adolescent female patient. Comprehensive care
Recommendations: For the adolescent patient, judicious during pregnancy should involve assessment of caries and
use of bleaching can be considered part of a comprehensive, periodontal disease risks along with discussion of the import-
sequenced treatment plan that takes into consideration the ance of a healthy diet, fluoride, and oral hygiene.96
patient’s dental developmental stage, oral hygiene, and caries
status. A dentist should monitor the bleaching process, ensur- Sexually-transmitted infections: There is a growing concern
ing the least invasive, most effective treatment method. Dental and increase in the prevalence of sexually transmitted disease in
professionals also should consider possible side effects when adolescents, specifically in the ages of 15-19 years.11 Screening
contemplating dental bleaching for adolescent patients.78-80 and examination for oral signs of sexually transmitted infections
and appropriate management or referral by the provider are
Tobacco, nicotine, alcohol, and recreational drug use: Signifi- important. Because human papilloma virus (HPV) has shown
cant oral, dental, and systemic health consequences and death a relationship with oral and oropharyngeal cancers, dentists
are associated with all current forms of tobacco use. These are in a unique position to discuss the HPV vaccination with
include the use of products such as cigars, cigarettes, snuff, patients and their parents.97
hookahs, smokeless tobacco, pipes, bidis, kreteks, dissolvable Recommendations: Screening and examination for oral
tobacco, and electronic cigarettes.81 Smoking and smokeless signs of sexually transmitted diseases should be part of com-
tobacco use are initiated and established primarily during prehensive care delivered to the adolescent patient. The
adolescence.82-85 There is increased risk in oral cancer from examination should include identifying oral manifestations of
chewing tobacco and an increased risk of lung and pancreatic sexually-transmitted diseases as well as education on the risk
cancers, cardiovascular disease, stroke, and risk-taking behav- of transmission during unprotected oral sex and adoption of
iors with use of nicotine, e-cigarettes, vaping, alcohol, and barrier techniques (e.g., condoms, dental dams) for prevention;
recreational drugs.86 In addition, use of these substances can referral for counseling and treatment is recommended when
have effects such as halitosis, extrinsic staining, and negative indicated.11 Patients also should be educated on HPV and
outcomes in sports performance.8 available vaccination to prevent risk of infection.97
Recommendations: The oral and systemic consequences of
all current forms of tobacco use should be part of each pa- Psychosocial and other considerations: Behavioral considerations
tient’s oral health education.87-89 For those adolescent patients when treating an adolescent may include anxiety, phobia, and
who use tobacco products, the practitioner should provide or intellectual dysfunction.21 Some psychosocial considerations
refer the patient to appropriate educational and counseling may result in oral problems (e.g., perimyolysis/severe enamel
services.90 Questions regarding tobacco use should be added to erosion in patients with bulimia).98
the adolescent dental record.91 When associated pathology is

The impact of psychosocial factors relating to oral health her individual needs. Many adolescent patients independently
must include consideration of the following: will choose the time to seek care from a general dentist and
• changes in dietary habits (e.g., fads, freedom to snack, may elect to seek treatment from a parent’s primary care
increased energy needs, access to carbohydrates). provider. In some instances, however, the treating pediatric
• use of tobacco, alcohol, and drugs. dentist will be required to suggest transfer to adult care.
• risk-taking or risk-seeking behavior. Pediatric dentists are concerned about decreased access
• motivation for maintenance of good oral hygiene. to oral health care for individuals with special health care
• adolescent as responsible for care. needs (SHCN)104 as they reach the age of majority. Pediatric
• lack of knowledge about periodontal disease. hospitals, by imposing age restrictions, can create a barrier
to care for these patients. Transitioning to a dentist who is
Physiologic changes also can contribute to significant oral knowledgeable and comfortable with adult oral health care
concerns in the adolescent. These changes include: (1) loss of needs is important and, in some instances, difficult due to a
remaining primary teeth; (2) eruption of remaining perma- lack of trained providers willing to accept this responsibility.
nent teeth; (3) gingival maturity; (4) facial growth; and (5) Successful transitioning from pediatric to adult special needs
hormonal changes. dentistry involves the patient and his caregiver(s), adequate
Although new studies show that neurologic maturation preparation, and understanding of the complex situations
continues into the third decade of life, seeking assent from relating to care.105
adolescents for intervention can foster the moral growth and Recommendations: At a time agreed upon by the patient,
development of autonomy in young patients. 99,100 Refer to parent, and pediatric dentist, the patient should be transitioned
AAPD’s Best Practice on Informed Consent for further to a dentist knowledgeable and comfortable with managing
information.101 that patient’s specific oral care needs. For the patient with
Recommendations: SHCN, in cases where it is not possible or desired to transition
1. An adolescent’s oral health care should be provided by a to another practitioner, the dental home can remain with the
dentist who has appropriate training in managing the pediatric dentist and appropriate referrals for specialized dental
patient’s specific needs. Referral should be made when care should be recommended when needed.103
the treatment needs are beyond the treating dentist’s
scope of practice. This may include both dental and References
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care for the pregnant adolescent. The Reference Manual
of Pediatric Dentistry. Chicago, Ill.: American Academy

BEST PRACTICES: PREGNANT ADOLESCENT
Oral Health Care for the Pregnant Adolescent

Latest Revision How to Cite: American Academy of Pediatric Dentistry. Oral health
2016 care for the pregnant adolescent. The Reference Manual of Pediatric
2020:267-74.
Purpose consequences for mothers and their children and imposes high
The American Academy of Pediatric Dentistry (AAPD), as public sector costs.6 Eighty-two percent of adolescent preg-
the oral health advocate for infants, children, adolescents, and nancies are not planned.7,8 More than half of these pregnancies
persons with special needs, recognizes that adolescent preg- (59 percent) end in births, 14 percent result in miscarriages,
nancy remains a significant social and health issue in the U.S. and 27 percent result in abortion.7
These recommendations are intended to address management There exist economic, racial, and ethnic disparities related
of oral health care particular to the pregnant adolescent rather to oral hygiene practices and dental service utilization during
than provide specific treatment recommendations for oral pregnancy; reports indicate minority pregnant adolescents had
conditions. only limited dental visits and possessed limited knowledge
of oral health and pregnancy outcomes.9,10 Little is known
Methods about individual characteristics or behaviors related to clinically
Recommendations on oral health care for the pregnant assessed oral health during pregnancy.11
adolescent were developed by the Council on Clinical Affairs Medical complications involving mother and child occur
Committee on the Adolescent and adopted in 2007. This more frequently in pregnant females aged 11 through 15 years
document by the Council of Clinical Affairs is a revision than those aged 20 to 22 years.5 These include the delivery of
of the previous version, last revised in 2012. The revision low-birth-weight infants, increased neonatal death rate, and
®
included a search of the PubMed /MEDLINE database
using the terms: teen pregnancy AND dental and adolescent
increased mortality rate for the mother.5 The socioeconomic
and cultural environments of the pregnant adolescent are
pregnancy. This search yielded 209 articles that met the related to the increased frequency of low-weight and prema-
defined criteria to update this document. The search then was ture newborns. 12 Pregnancy-induced hypertension, anemia,
narrowed to include articles that were limited to clinical trials, sexually transmissible diseases, and premature delivery also are
systematic reviews, or meta-analysis. When data did not concerns for the pregnant adolescent.5 Hypertension increases
appear sufficient or were inconclusive, recommendations were the risk of bleeding during procedures. Teens are at a higher
based upon expert and/or consensus opinion by experienced risk for pregnancy-related high blood pressure (preeclampsia)
researchers and clinicians. and its complications than older mothers.13 Preeclampsia is a
dangerous medical condition that combines high blood
Background pressure in women who have never before had high blood
General considerations pressure with proteinuria and swelling of the hands and
In 2014, a total of 249,067 infants were born to 15 through face.14 Risks for the baby include premature birth and low
19 year olds, for a live birth rate of 24.2 per 1,000 women birthweight. 13 Proper prenatal care is essential, and blood
in this age group.1 This is a nine percent decline from 2013 pressure monitoring, weighing in, and testing the urine for
(26.5 per 1,000) and represents an historic low for the U.S., protein should take place at each prenatal healthcare visit.15
with an overall decline of 61 percent since the peak in 1991 If an abnormal elevation in blood pressure is noted during a
(61.8 per 1,000).2 While the decline in the U.S. teen birth dental visit, the patient’s physician should be notified. Blood
rate is promising, the U.S. teen pregnancy rate still is sub- pressure greater than or equal to 140/90 mmHg is considered
stantially higher than other western industrialized nations.3 mild hypertension, whereas values greater than or equal to
The declines in teen birth rates reflect a number or behavioral 160/110 mmHg are considered severe.16 Acute-onset, severe
changes, including decreased sexual activity and increases in hypertension that persists for 15 minutes or more is considered
the use of contraception.4,5 Approximately 50 percent of an emergency. The physician should be notified immediately
adolescent pregnancies occur within the first six months of
initial sexual intercourse, even with increasing use of contra-
ceptives by adolescents.5 ABBREVIATIONS
The correlation between poverty and adolescent pregnancy AAPD: American Academy of Pediatric Dentistry. MS: Mutans
is great; many adolescent females who give birth are from low- streptococci. TOP: Teen Outreach Program.
income families.6 Teen childbearing may present unfavorable

as untreated severe hypertension can have significant morbidity to the relative safety of the medication for use by pregnant
(e.g., hemorrhagic stroke) or mortality.17 women. Category A includes drugs that have been studied in
The diet of the pregnant adolescent can affect the health humans and have evidence supporting their safe use; category
of the child. A healthy diet is necessary to provide adequate B drugs show no evidence of risk to humans. Generally, these
amounts of nutrients to the mother-to-be and the unborn drugs are considered acceptable for use during pregnancy.32
child. Recommended dietary allowances during pregnancy Category C drugs, such as aspirin and aspirin-containing prod-
and lactation are tabulated as absolute figures rather than ucts, may be used with caution, whereas drugs in categories
additions to the basic allowances.18 Nutrients of particular D (e.g., tetracycline) and X are not intended for use during
importance include folate (folic acid), calcium, magnesium, pregnancy. The Organization of Teratology Information Ser-
zinc, and vitamins K, C, B6 and B12.18 Maternal levels of vices provides useful national information for drug safety
vitamin D during pregnancy may affect the developing pri- during pregnancy.35
mary dentition, with lower levels altering enamel integrity and Low socioeconomic status and lack of parental involvement
increasing the risk for early childhood caries. 19 Folic acid, a can place an adolescent at increased risk of initiating tobacco
B vitamin, plays an important role in the production of cells use.36 Smoking during pregnancy is associated with adverse
and helps in the development of the neural tube, the brain, outcomes.36,37 Women who smoke may have increased risks
and spinal cord.20 Folic acid supplementation has been shown for ectopic pregnancy, spontaneous abortion, and preterm de-
to decrease the risk of isolated cleft lip with or without cleft livery.36,37 Infants born to women who smoke during pregnancy
palate.21 A recent study supports the hypothesis that folate are more likely to be small for gestational age and have low
supplements play a significant role in preventing cleft lip birthweight. 36-39 The longer the mother smokes during
and palate when taken in the first 12 weeks of pregnancy.22 pregnancy, the greater the effect on the infant’s birthweight.37
The growing benefits of folic acid and the importance of Increasing evidence shows that maternal tobacco use is
folic acid supplements should be included as part of prenatal associated with intellectual disability and birth defects such as
counseling. 20 Assessment of folic acid status in children oral clefts.36 The risk for perinatal mortality and sudden infant
having orofacial clefting is yet to be evaluated in depth.23 death syndrome (SIDS) is increased for infants of women who
During pregnancy, a woman’s nutritional needs are in- smoke. 36,37 Infants and children exposed to environmental
creased, but certainly the eating for two concept is not recom- tobacco smoke have higher rates of lower respiratory illness,
mended. 24 The total energy needs during pregnancy range middle ear infections, asthma, and caries in the primary den-
between 2,500 to 2,700 kcal a day for most women, but tition. 36-41 Women are more likely to stop smoking during
pre-pregnancy body mass index, rate of weight gain, maternal pregnancy, both spontaneously and with assistance, than at
age, and physiological appetite must be considered in tailoring other times in their lives.37
this recommendation to the individual.25 Poor prenatal dietary
intakes of energy, protein, and micronutrients have been Oral conditions associated with pregnancy
shown to be associated with increased risk of adult obesity in Physiologic changes in the oral cavity during pregnancy are
off-spring.26 Recent studies have shown that improving the well documented.42 These include alterations in both the hard
nutritional status of women prior to and during pregnancy and soft tissues. An increase in caries has been associated with
can reduce the risk of low-birth-weight babies substantially. 26 carbohydrate loading as snacking becomes more frequent.42
Nausea and vomiting are common during the first trimester Nausea and vomiting are common and occur in 70-85 percent
and often are associated with young age and low socioeconomic of women, but are usually self-limiting after the first trimester.
status.27 An expectant female may modify food choices due Persistent, severe vomiting (hyperemesis gravidarum) is rare
to morning sickness and/or taste aversions, but appropriate (0.3-2 percent of pregnancies),43 but may contribute to the
nutrition for the health of the mother and fetus is crucial. onset of perimyolysis, an erosion of the lingual surfaces of the
Nausea and vomiting may cause a woman to avoid routine teeth caused by exposure to gastric acids. A confounding factor
oral health practices such as toothbrushing and flossing. This is that pregnancy-associated hormonal changes may cause
could lead to dental caries and gingivitis.28-30 Gingivitis is re- dryness of the mouth. Approximately 44 percent of pregnant
ported to be the most common oral disease during pregnancy.31 participants in one study reported persistent xerostomia.44
The goal of any drug therapy during pregnancy is to im- Signs of gingivitis (e.g., bleeding, redness, swelling, tender-
prove maternal/fetal health while avoiding adverse drug re- ness) are evident in the second trimester and peak in the
actions.32 Reporting that medications for pregnant patients eighth month of pregnancy, with anterior teeth affected more
sometimes are prescribed under less than optimal conditions, a than posterior teeth.45 These findings are exacerbated by poor
study of obstetrician-gynecologists emphasizes the importance plaque control and mouth breathing. 46 From a periodontal
of generating and having available to heath care providers up-to- perspective, the effects of hormonal levels on the gingival status
date information on effects of medications during pregnancy.33 of pregnant women may be accompanied by increased levels
The U.S. Food and Drug Administration has defined drug of progesterone and estrogen which contribute to increased
categories according to the risk they pose to pregnant women vascularity, permeability, and possible tissue edema.47,48 Evidence
and their fetuses.34 These categories provide some guidance shows a relationship of periodontal disease and gestational

diabetes which contributes to maternal and infant morbidity pregnancy outcomes.68,69 Currently, there is no evidence that
as well as the risk of the mother developing type 2 diabetes the exposure of a fetus to mercury release from the mother’s
mellitus.45,49 existing amalgam fillings causes any adverse effects.67,69 Mercury
The study of periodontitis during pregnancy and its effect vapor released during the removal or placement of amalgam
on preterm, low-birth-weight infants is ongoing. Early studies restorations may be inhaled and absorbed into the blood
noted an increase rate of preterm/low-birth-weight deliveries stream and does cross the placental barrier. The use of rubber
associated with periodontal disease.45,50,51 However, a more re- dam and high speed suction can reduce the risk of vapor in-
cent study of 116 postpartum women noted clinical attachment halation. 70 Because use of tooth whitening products that
level measures were not different between those with preterm/ contain or generate hydrogen peroxide results in release of
low-birth-weight babies and control groups. Therefore, ma- inorganic mercury from dental amalgams, these products
ternal periodontal microbiota and clinical characteristics of should be used with caution during pregnancy.67
periodontal disease were not associated with having preterm/ During dental radiographic examination of a pregnant
low-birth-weight babies. 52 Additional studies continue to patient, optimizing techniques, shielding the thyroid and
demonstrate conflicting results.53-60 The effect of periodontitis abdomen, choosing the fastest available image receptor (i.e.,
and the development of preeclampsia, a rapidly progressing high-speed film, rare earth screen-film systems, digital
condition occurring in pregnancy characterized by hyperten- radiography), and avoiding retakes help minimize radiation
sion and the presence of proteinuria, continues to be studied exposure to the fetus.71,72 The primary dental X-ray beam may
as well.55,59-62 pass near or through the thyroid gland, even with attention to
Poor plaque control coupled with hormonal changes may proper radiographic techniques. The juvenile thyroid is among
lead to the development of a pyogenic granuloma (i.e., preg- the most sensitive organs to radiation-induced tumors, both
nancy tumor or granuloma gravidarum). This benign vascular benign and malignant.72 Risk decreases significantly with age
lesion appears as a deep red to purple gingival nodule in the at exposure, essentially disappearing after age 20. 72 Evidence
second or third trimester of pregnancy.46,63 Although the lesion shows that radiation exposure to the thyroid during pregnancy
may regress postpartum, surgical excision may be necessary.63 is associated with low birthweight.71 Common dental projec-
tions rarely, if ever, deliver a measurable absorbed dose to the
Oral health care during pregnancy embryo or fetus.72 Gonadal absorbed dose from a typical dental
A multi-state study concluded that, besides neglecting medical X-ray procedure is equivalent to about one hour of natural
care during pregnancy, most expectant females of all ages do background radiation.72 The National Council on Radiation
not seek dental care, even though 50 percent of them have a Protection and Measurements recommends if dental treatment
dental problem.15 One study reported the most significant is to be deferred until after the delivery, so should the dental
predictor of not receiving routine dental care during pregnancy radiographs. 72 Once the decision to obtain radiographs is
was a woman’s lack of routine dental care when not pregnant.9 made, it is the dentist’s responsibility to follow the as low as
Although an expectant mother might question the safety of reasonably achievable (ALARA principle) to minimize the
dental treatment during pregnancy, untreated oral disease may patient’s exposure.70
compromise the health of the pregnant female and the un- Suppression of the mother’s reservoirs of Mutans strep-
born child.64,65 The consequences of not treating an active tococci (MS) by dental rehabilitation and antimicrobial
infection during pregnancy outweigh the possible risks pre- treatments may prevent or at least delay infant acquisition of
sented by most of the medications required for dental care.33 these cariogenic microorganisms.73 MS, present in children
In addition, deferring elective dental treatment during a with early childhood caries, is predominantly acquired from
healthy pregnancy is not justified.65 mother’s saliva.74 The transmission of cariogenic bacteria from
The objectives of professional oral health care during the mother to infant is increased when the mother has poor
first trimester include avoiding fetal hypoxia, premature labor/ oral health with untreated dental caries.75 MS colonization of
fetal demise, and teratogenic effects.60 Due to the increased risk an infant may occur from the time of birth. 75-83 Improving
of pregnancy loss, use of nitrous oxide may be contraindicated oral health during pregnancy leads to a reduction in salivary
in the first trimester of pregnancy.61 Because the pregnant MS in the offspring.73
uterus is below the umbilicus, the woman is generally more Education is an important component of prenatal oral
comfortable for treatment during weeks 14 to 20 of gestation. health care and may have a significant effect on the oral health
Pregnant women are considered to have a full stomach due of both the mother and the child. Counseling for the pregnant
to delayed gastric emptying and, therefore, are at increased adolescent includes topics directed toward all adolescent pa-
risk for aspiration, particularly during the last trimester.66-68 tients (e.g., dietary habits, injury prevention, third molars),
Elective restorative and periodontal therapies during the as well as oral changes that may occur during pregnancy and
second trimester may prevent any dental infections or other infant oral healthcare. Since the pregnant adolescent may be
complications from occurring in the third trimester.65 receptive to information that will improve the infant’s health,
Evidence is insufficient to support or refute that mercury anticipatory guidance, a proactive developmentally-based
exposure from dental amalgams contributes to adverse counseling technique, can be introduced to focus on the needs

of the child at each stage of life. Studies have documented Because risk of carcinogenesis or fetal effects is very small but
that early oral health promotion starting during pregnancy can significant, radiographs should be obtained only when there
lead to a sustained and long-term improvement of the oral is expectation that diagnostic yield (including the absence of
health of children.84,85 Programs that promote oral health must pathology) will influence patient care.72 If dental treatment
continue to inform pregnant women and care providers about must be deferred until after delivery, radiographic assessment
the importance of dental care before, during, and after preg- also should be deferred. All radiographic procedures should be
nancy. Oral health counseling during pregnancy and dental conducted in accordance with radiation safety practices. These
cleanings are recommended.86 Mobile phone texting components include optimizing the radiographic techniques, shielding the
added as a supplement to the Teen Outreach Program (TOP), pelvic region and thyroid gland, and using the fastest imaging
a youth development program for reducing teen pregnancy available.72
and school dropout, has proven helpful in disseminating and Counseling for all pregnant patients should address:
sharing information to minority youth.87 TOP can be used to • relationship of maternal oral health with fetal health61
address issues regarding oral health. (e.g., possible association of periodontal disease with
preterm birth and pre-eclampsia, developmental de-
Legal considerations fects in the primary dentition19);
Statutes and case law concerning consent involving pregnant • an individualized preventive plan including oral hy-
patients less than 18 years of age vary from state to state. In giene instructions, rinses, and/or xylitol products to
some states, dentists are required to obtain parental consent decrease the likelihood of MS transmission post-
for non-emergency dental services provided to a child 17 years partum;92-94
of age or younger who remains under parental care.88 This • dietary considerations (e.g., maintaining a healthy diet,
would involve obtaining consent from the parent who must avoiding frequent exposures to cariogenic foods and
be aware of the pregnancy in order to understand the risks beverages, overall nutrient and energy needs)61,62 and
and benefits of the proposed dental treatment.65 However, if vitamin supplements19-21;
the parent is unaware of the pregnancy, the pregnant adoles- • anticipatory guidance for the infant’s oral health in-
cent may be entitled to confidentiality regarding health issues cluding the benefits of early establishment of a dental
such as the pregnancy.89 In other states, there are mature minor home;84,85
laws that allow minors to consent for their own health care • anticipatory guidance for the adolescent’s oral health
when a dentist deems the minor competent to provide in to include injury prevention, oral piercings, tobacco
formed consent. In addition, some states emancipate minors and substance abuse, sealants, and third molar assess-
who are pregnant or by court order. Practitioners are obligated ment;95
to be familiar with and abide by the laws specific to where • oral changes that may occur secondary to preg-
they practice and where the patient resides. nancy45,50 (e.g., xerostomia, shifts in oral flora); and
• individualized treatment recommendations based
Recommendations upon the specific oral findings for each patient.
The AAPD recommends that all pregnant adolescents seek
professional oral health care during the first trimester. After Preventive services must be a high priority for the ado-
obtaining a thorough medical history, the dental professional lescent pregnant patient. Ideally, a dental prophylaxis should
should perform a comprehensive evaluation which includes a be performed during the first trimester and again during the
thorough dental history, dietary history, clinical examination, third trimester if oral home care is inadequate or periodontal
and caries risk assessment. The dental history should include conditions warrant professional care. Referral to a periodontist
discussion of preexisting oral conditions, current oral hygiene should be considered in the presence of progressive periodon-
practices and preventive home care, previous radiographic tal disease.45,50 While fluoridated dentifrice and professionally-
exposures, and tobacco use.36-41 The adolescent’s dietary history applied topical fluoride treatments can be effective caries
should focus on exposures to carbohydrates, especially due to preventive measures for the expectant adolescent, the AAPD
increased snacking, and acidic beverages/foods. During the does not support the use of prenatal fluoride supplements to
clinical examination, the practitioner should pay particular at- benefit the fetus.96
tention to health status of the periodontal tissues. The AAPD’s A pregnant adolescent experiencing morning sickness or
caries-risk assessment guideline, utilizing historical and clini- gastroesophageal reflux should be instructed to rinse with a
cal findings, will aid the practitioner in identifying risk factors cup of water containing a teaspoon of sodium bicarbonate
in order to develop an individualized preventive program.90 and to avoid tooth brushing for about one hour after vomiting
Improving the oral health of pregnant women reduces com- to minimize dental erosion caused by stomach acid expo-
plications of dental diseases during pregnancy to both the sure.9 Women should be advised about the high sugar content
mother and the developing fetus.91 and risk for caries associated with long term frequent use of
Based upon the historical indicators, clinical findings, and over-the-counter antacids. Where there is established erosion,
previous radiographic surveys, radiographs may be indicated. fluoride may be used to minimize hard tissue loss and control

sensitivity. A daily neutral sodium fluoride mouth rinse or 4. Haffner DW. Facing Facts: Sexual Health for America’s
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83. Law V, Seow WK, Townsend G. Factors influencing oral caries in the United States. Centers for Disease Control
colonization of mutans streptococci in young children. and Prevention. MMWR Recomm Rep 2001;50(RR-14):
Aust Dent J 2007;52(2):93-100. 1-42.
84. Murphey C, Rew L. Three intervention models for 97. Linnett V, Seow WK. Dental erosion in children: A
exploring oral health in pregnant minority adolescents. literature review. Pediatr Dent 2001;23(1):37-43.
J Spec Pediatr Nurs 2009;14(2):132-41. 98. English A, Ford CA. The HIPAA privacy rule and ado-
85. Meyer K, Geurtsen W, Günay H. An early oral health lescents: Legal questions and clinical challenges. Perspect
care program starting during pregnancy: Results of a Sex Reprod Health 2004;36(2):80-6.
prospective clinical long-term study. Clin Oral Investig
2010;14(3):257-64.

BEST PRACTICES: MANAGEMENT OF SHCN PATIENTS
Management of Dental Patients with Special

Health Care Needs
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Management
2016 of dental patients with special health care needs. The Reference
Purpose daily self-maintenance activities or substantial limitations in a

The American Academy of Pediatric Dentistry (AAPD) major life activity. Health care for individuals with special needs
recognizes that providing both primary and comprehensive requires specialized knowledge, as well as increased awareness
preventive and therapeutic oral health care to individuals with and attention, adaptation, and accommodative measures be-
special health care needs (SHCN) is an integral part of the yond what are considered routine.”3
specialty of pediatric dentistry.1 The AAPD values the unique Individuals with SHCN may be at an increased risk for
qualities of each person and the need to ensure maximal oral diseases throughout their lifetime.2,4-6 Oral diseases
health attainment for all, regardless of developmental disability can have a direct and devastating impact on the health and
or other special health care needs. These recommenda- quality of life of those with certain systemic health problems
tions were intended to educate health care providers, parents, or conditions. Patients with compromised immunity (e.g.,
and ancillary organizations about the management of oral leukemia or other malignancies, human immunodeficiency
health care needs particular to individuals with SHCN rather virus) or cardiac conditions associated with endocarditis may
than provide specific treatment recommendations for oral be especially vulnerable to the effects of oral diseases.7 Patients
conditions. with mental, developmental, or physical disabilities who do
not have the ability to understand, assume responsibility for,
Methods or cooperate with preventive oral health practices are suscep-
Recommendations on the management of dental patients with tible as well.8 Oral health is an inseparable part of general
SHCN were developed by the Council on Clinical Affairs health and well-being.4
and adopted in 2004. This document is a revision of the SHCN also includes disorders or conditions which manifest
previous version, last revised in 2012. This update is based only in the orofacial complex (e.g., amelogenesis imperfecta,
on a review of the current dental and medical literature dentinogenesis imperfecta, cleft lip/palate, oral cancer). While
related to individuals with SHCN. An search was conducted these patients may not exhibit the same physical or commu-
®
via PubMed /MEDLINE using the terms: special needs, nicative limitations of other patients with SHCN, their needs
disability, disabled patients/persons/children, handicapped pa- are unique, impact their overall health, and require oral health
tients, dentistry, dental care, and oral health; fields: all; limits: care of a specialized nature.
within the last 10 years, human, English, and clinical trials. According to the U.S. Census Bureau, approximately 37.9
Papers for review were chosen from the resultant list of million Americans have a disability, with about two-thirds of
articles and from references within selected articles. When these individuals having a severe disability.9 The proportion
data did not appear sufficient or were inconclusive, recom- of children in the U.S. with SHCN is estimated to be 18 per-
mendations were based on expertand/or consensus opinion cent, approximately 12.5 million.10 Because of improvements
by experienced researchers and clinicians, including papers in medical care, patients with SHCN will continue to grow in
and workshop reports from the AAPD-sponsored symposium number; many of the formerly acute and fatal diagnoses have
“Lifetime Oral Health Care for Patients with Special Needs” become chronic and manageable conditions. The Americans
(Chicago, Ill.; November, 2006).2 with Disabilities Act (AwDA) defines the dental office as a
place of public accommodation.11 Thus, dentists are obligated
Background to be familiar with these regulations and ensure compliance.
The AAPD defines special health care needs as “any physical,
developmental, mental, sensory, behavioral, cognitive, or emo-
tional impairment or limiting condition that requires medical
ABBREVIATIONS
management, health care intervention, and/or use of specialized AAPD: American Academy of Pediatric Dentistry. AwDA: Ameri-
services or programs. The condition may be congenital, cans with Disabilities Act. HIPAA: Health Insurance Portability
developmental, or acquired through disease, trauma, or envi- and Accountability Act. SHCN: Special health care needs.
ronmental cause and may impose limitations in performing

Failure to accommodate patients with SHCN could be con- it difficult for general dentists to obtain hospital privileges.
sidered discrimination and a violation of federal and/or state Outpatient surgery centers and in office general anesthesia may
law. Regulations require practitioners to provide physical access be alternatives, although they may not be appropriate to treat
to an office (e.g., wheelchair ramps, disabled-parking spaces); patients with special needs due to medical complexity.26
however, individuals with SHCN can face many barriers to Transitioning to a dentist who is knowledgeable and com-
obtaining oral health care. fortable with adult oral health care needs often is difficult
Families with SHCN children experience much higher ex- due to a lack of trained providers willing to accept the
penditures than required for healthy children. Because of the responsibility of caring for SHCN patients.27,28 It should be
unmet dental care needs of individuals with SHCN, emphasis noted that the Commission on Dental Accreditation of the
on a dental home and comprehensive, coordinated services American Dental Association introduced an accreditation
should be established.11,12 Optimal health of children is more standard requiring dental schools to ensure that curricular
likely to be achieved with access to comprehensive health care efforts are focused on educating their students on how to
benefits.13 Financing and reimbursement have been cited as assess treatment needs of patients with SHCN.29,30
common barriers for medically necessary oral health care.14,15
Insurance plays an important role for families with children Recommendations
who have SHCN, but it still provides incomplete protection.16-18 Scheduling appointments
Furthermore, as children with disabilities reach adult-hood, The parent’s/patient’s initial contact with the dental practice
health insurance coverage may be restricted.17,19,20 allows both parties an opportunity to address the child’s pri-
Many individuals with SHCN rely on government funding mary oral health needs and to confirm the appropriateness of
to pay for medical and dental care and lack adequate access to scheduling an appointment with that particular practitioner.
private insurance for health care services.19 Lack of preventive Along with the child’s name, age, and chief complaint, the
and timely therapeutic care may increase the need for costly receptionist should determine the presence and nature of any
care and exacerbate systemic health issues.10 SHCN and, when appropriate, the name(s) of the child’s
Nonfinancial barriers such as language and psychosocial, medical care provider(s). The office staff, under the guidance of
structural, and cultural considerations may interfere with ac- the dentist, should determine the need for an increased length
cess to oral health care.18 Effective communication is essential of appointment and/or additional auxiliary staff in order to
and, for hearing impaired patients/parents, can be accom- accommodate the patient in an effective and efficient manner.
plished through a variety of methods including interpreters, The need for increased dentist and team time as well as cus-
written materials, and lip-reading. Psychosocial factors associ- tomized services should be documented so the office staff is
ated with access for patients with SHCN include oral health prepared to accommodate the patient’s unique circumstances
beliefs, norms of caregiver responsibility, and past dental at each subsequent visit.31
experience of the caregiver. Structural barriers include tran- When scheduling patients with SHCN, it is imperative
sportation, school absence policies, discriminatory treatment, that the dentist be familiar and comply with Health Insur-
and difficulty locating providers who accept Medicaid.14 ance Portability and Accountability Act (HIPAA) and AwDA
Community-based health services, with educational and social regulations applicable to dental practices.32 HIPAA insures
programs, may assist dentists and their patients with SHCN.21 that the patient’s privacy is protected and AwDA prevents
Priorities and attitudes can serve as impediments to oral discrimination on the basis of a disability.
care. Parental and physician lack of awareness and knowledge
may hinder an individual with SHCN from seeking preven- Dental home
tive dental care.22 Other health conditions may seem more Patients with SHCN who have a dental home33 are more likely
important than dental health, especially when the relationship to receive appropriate preventive and routine care. The dental
between oral health and general health is not well understood.23 home provides an opportunity to implement individualized
Persons with SHCN patients may express a greater level of preventive oral health practices and reduces the child’s risk of
anxiety about dental care than those without a disability, which preventable dental/oral disease.
may adversely impact the frequency of dental visits and, sub- When patients with SHCN reach adulthood, their oral
sequently, oral health.24 health care needs may extend beyond the scope of the pedi-
Pediatric dentists are concerned about decreased access to atric dentist’s training. It is important to educate and prepare
oral health care for patients with SHCN as they transi- the patient and parent on the value of transitioning to a dentist
tion beyond the age of majority.25 Finding a dental home for who is knowledgeable in adult oral health needs. At a time
non-pediatric SHCN patients could be challenging. Pediatric agreed upon by the patient, parent, and pediatric dentist, the
hospitals, by imposing age restrictions, can create another patient should be transitioned to a dentist knowledgeable and
barrier to care for these patients. This presents difficulties for comfortable with managing that patient’s specific health care
pediatric dentists providing care to adult SHCN patients who needs. In cases where this is not possible or desired, the dental
have not yet transitioned to adult primary care. Some pediatric home can remain with the pediatric dentist and appropriate
hospitals require dentists to be board certified, thus making referrals for specialized dental care should be recommended
when needed.34

Patient assessment patient’s visit can assist greatly in preparation for the appoint-
Familiarity with the patient’s medical history is essential to ment.8 An attempt should be made to communicate directly
decreasing the risk of aggravating a medical condition while with the patient and, when indicated, to supplement commu-
rendering dental care. An accurate, comprehensive, and up-to- nication with gestures and augmentive methods of commu-
date medical history is necessary for correct diagnosis and nication during the provision of dental care. A patient who
effective treatment planning. Information regarding the chief does not communicate verbally may communicate in a variety
complaint, history of present illness, medical conditions and/ of non-traditional ways. At times, a parent, family member, or
or illnesses, medical care providers, hospitalizations/surgeries, caretaker may need to be present to facilitate communication
anesthetic experiences, current medications, allergies/ and/or provide information that the patient cannot. According
sensitivities, immunization status, review of systems, family to the requirements of the AwDA, if attempts to communicate
and social histories, and thorough dental history should be with a patient with SHCN/parent are unsuccessful because
obtained.35 As many children with SHCN may have sensory of a disability such as impaired hearing, the dentist must work
issues that can make the dental experience challenging, the with those individuals to establish an effective means of
dentist should include such considerations during the history communications.11
intake and be prepared to modify the traditional delivery of
dental care to address the child’s unique needs. If the patient/ Planning dental treatment
parent is unable to provide accurate information, consulta- The process of developing a dental treatment plan typically
tion with the caregiver or with the patient’s physician may be progresses through several steps. Before a treatment plan can
required. be developed and presented to the patient and/or caregiver,
At each patient visit, the history should be consulted and information regarding medical, physical, psychological, social,
updated. Recent medical attention for illness or injury, newly behavioral, and dental histories must be gathered37 and clini-
diagnosed medical conditions, and changes in medications cal examination and any additional diagnostic procedures
should be documented. A written update should be obtained completed.
at each recall visit. Significant medical conditions should be
identified in a conspicuous yet confidential manner in the Informed consent
patient’s record. All patients must be able to provide signed informed consent
Comprehensive head, neck, and oral examinations should for dental treatment or have someone present who legally can
be completed on all patients. A caries-risk assessment should provide this service for them. Informed consent/assent must
be performed.36 Caries-risk assessment provides a means of comply with state laws and, when applicable, institutional
classifying caries risk at a point in time and, therefore, should requirements. Informed consent should be well documented
be applied periodically to assess changes in an individual’s risk in the dental record through a signed and witnessed form.38
status. The examination also should include assessments of
trauma and periodontal risk. An individualized preventive Behavior guidance
program, including a dental recall schedule, should be recom- Behavior guidance of the patient with SHCN can be challen-
mended after evaluation of the patient’s caries risk, oral health ging. Because of dental anxiety or a lack of understanding of
needs, and abilities. dental care, children with disabilities may exhibit resistant
A summary of the oral findings and specific treatment rec- behaviors. These behaviors can interfere with the safe delivery
ommendations should be provided to the patient and parent/ of dental treatment. With the parent/caregiver’s assistance, most
caregiver. When appropriate, the patient’s other care providers patients with physical and mental disabilities can be managed
(e.g., physicians, nurses, social workers) should be informed in the dental office. Protective stabilization can be helpful in
of any significant findings. patients for whom traditional behavior guidance techniques
are not adequate.39 When protective stabilization is not feas-
Medical consultations ible or effective, sedation or general anesthesia is the behavioral
The dentist should coordinate care via consultation with the guidance armamentarium of choice. When in-office sedation/
patient’s other care providers. When appropriate, the physician general anesthesia is not feasible or effective, an out-patient
should be consulted regarding medications, sedation, general surgical care facility might be necessary.
anesthesia, and special restrictions or preparations that may
be required to ensure the safe delivery of oral health care. Preventive strategies
The dentist and staff always should be prepared to manage a Individuals with SHCN may be at increased risk for oral
medical emergency. diseases; these diseases further jeopardize the patient’s health.3
Education of parents/caregivers is critical for ensuring appro-
Patient communication priate and regular supervision of daily oral hygiene. The team
When treating patients with SHCN, similar to any other child, of dental professionals should develop an individualized oral
developmentally-appropriate communication is critical. Often, hygiene program that takes into account the unique disability
information provided by a parent or caregiver prior to the of the patient. Brushing with a fluoridated dentifrice twice

daily should be emphasized to help prevent caries and gingivi- Patients with developmental or acquired orofacial
tis. If a patient’s sensory issues cause the taste or texture of conditions
fluoridated toothpaste to be intolerable, a fluoridated mouth The oral health care needs of patients with developmental or
rinse may be applied with the toothbrush. Toothbrushes can acquired orofacial conditions necessitate special considerations.
be modified to enable individuals with physical disabilities to While these individuals usually do not require longer appoint-
brush their own teeth. Electric toothbrushes and floss holders ments or advanced behavior guidance techniques commonly
may improve patient compliance. Caregivers should provide associated with children having SHCN, management of their
the appropriate oral care when the patient is unable to do so oral conditions presents other unique challenges.46 Develop-
adequately. mental defects such as hereditary ectodermal dysplasia, where
A non-cariogenic diet should be discussed for long term most teeth are missing or malformed, cause lifetime problems
prevention of dental disease.40 When a diet rich in carbohy- that can be devastating to children and adults.4 From the first
drates is medically necessary (e.g., to increase weight gain), contact with the child and family, every effort must be made
the dentist should provide strategies to mitigate the caries risk to assist the family in adjusting to and understanding the
by altering frequency of and/or increasing preventive meas- complexity of the anomaly and the related oral needs.47 The
ures. As well, other oral side effects (e.g., xerostomia, gingival dental practitioner must be sensitive to the psychosocial
overgrowth) of medications should be reviewed. well-being of the patient, as well as the effects of the condition
Patients with SHCN may benefit from sealants. Sealants on growth, function, and appearance. Congenital oral conditions
reduce the risk of caries in susceptible pits and fissures of may entail therapeutic intervention of a protracted nature,
primary and permanent teeth.41 Topical fluorides may be in- timed to coincide with developmental milestones. Patients
dicated when caries risk is increased.42 Interim therapeutic with conditions such as ectodermal dysplasia, epidermolysis
restoration (ITR), 43 using materials such as glass ionomers bullosa, cleft lip/palate, and oral cancer frequently require an
that release fluoride, may be useful as both preventive and interdisciplinary team approach to their care. Coordinating
therapeutic approaches in patients with SHCN.41 In cases of delivery of services by the various health care providers can
gingivitis and periodontal disease, chlorhexidine mouth rinse be crucial to successful treatment outcomes.
may be useful. For patients who might swallow a rinse, a Patients with oral involvement of conditions such as osteo-
toothbrush can be used to apply the chlorhexidine. Patients genesis imperfecta, ectodermal dysplasia, and epidermolysis
having severe dental disease may need to be seen every two to bullosa often present with unique financial barriers. Although
three months or more often if indicated. Those patients with the oral manifestations are intrinsic to the genetic and congen-
progressive periodontal disease should be referred to a perio- ital disorders, medical health benefits often do not provide
dontist for evaluation and treatment. for related professional oral health care. The distinction made
Preventive strategies for patients with SHCN should by third party payors between congenital anomalies involving
address traumatic injuries. This would include anticipatory the orofacial complex and those involving other parts of the
guidance about risk of trauma (e.g., with seizure disorders or body is often arbitrary and without merit.48 For children with
motor skills/coordination deficits), mouthguard fabrication, hereditary hypodontia and/or oligodontia, removable or fixed
and what to do if dentoalveolar trauma occurs. Addition- prostheses (including complete dentures or over-dentures) and/
ally, children with SHCN are more likely to be victims of or implants may be indicated.49 Dentists should work with
physical abuse, sexual abuse, and neglect when compared to the insurance industry to recognize the medical indication
children without disabilities.44 Craniofacial, head, face, and and justification for such treatment in these cases.
neck injuries occur in more than half of the cases of child
abuse.45 Because of this incidence, dentists need to be aware Referrals
of signs of abuse and mandated reporting procedures.44,45 A patient may suffer progression of his/her oral disease if
treatment is not provided because of age, behavior, inability to
Barriers cooperate, disability, or medical status. Postponement or denial
Dentists should be familiar with community-based resources of care can result in unnecessary pain, discomfort, increased
for patients with SHCN and encourage such assistance when treatment needs and costs, unfavorable treatment experiences,
appropriate. While local hospitals, public health facilities, and diminished oral health outcomes. Dentists have an obli-
rehabilitation services, or groups that advocate for those with gation to act in an ethical manner in the care of patients. 50
SHCN can be valuable contacts to help the dentist/patient Once the patient’s needs are beyond the skills of the practi-
address language and cultural barriers, other community-based tioner, the dentist should make necessary referrals in order
resources may offer support with financial or transportation to ensure the overall health of the patient.
considerations that prevent access to care.34
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2003;27(10):1179-86.

BEST PRACTICES: CHILD ABUSE AND NEGLECT
Oral and Dental Aspects of Child Abuse and

Neglect
Developed by
American Academy of Pediatric Dentistry and
How to Cite: Fisher-Owens SA, Lukefahr JL, Tate AR, American Academy
of Pediatric Dentistry, Council on Clinical Affairs, Council on Scientific
American Academy of Pediatrics Affairs, Ad Hoc Work Group on Child Abuse and Neglect, American
Academy of Pediatrics, Section on Oral Health Committee on Child
Latest Revision Abuse and Neglect. Oral and dental aspects of child abuse and neglect.
2017 Pediatr Dent 2017;39(4):278-83.
Abstract
In all 50 states, health care providers (including dentists) are mandated to report suspected cases of abuse and neglect to social service
or law enforcement agencies. The purpose of this report is to review the oral and dental aspects of physical and sexual abuse and dental
neglect in children and the role of pediatric care providers and dental providers in evaluating such conditions. This report addresses
the evaluation of bite marks as well as perioral and intraoral injuries, infections, and diseases that may raise suspicion for child abuse
or neglect. Oral health issues can also be associated with bullying and are commonly seen in human trafficking victims. Some medical
providers may receive less education pertaining to oral health and dental injury and disease and may not detect the mouth and gum
findings that are related to abuse or neglect as readily as they detect those involving other areas of the body. Therefore, pediatric care
providers and dental providers are encouraged to collaborate to increase the prevention, detection, and treatment of these conditions in
children.
Children may be exposed to multiple kinds of maltreatment oral trauma, caries, gingivitis, and other oral health problems,
that manifests in the mouth, so health care professionals which are more prevalent in maltreated children than in the
(including dental providers) need to be aware of how to evaluate general pediatric population.7
and address these concerns. Maltreatment includes physical Some authorities believe that the oral cavity may be a
and sexual abuse and can include evidence of bite marks and central focus for physical abuse because of its significance in
dental neglect. Bullying and the human trafficking of chil- communication and nutrition.8 Oral injuries may be inflicted
dren also occur and can have serious long-term effects. These with instruments such as eating utensils or a bottle during
issues may be the presenting problem, noticed during a forced feedings, hands, fingers, scalding liquids, or caustic sub-
physical examination, or children or adolescents may disclose stances. This form of abuse may result in contusions; burns
information about experiencing abuse or neglect. It is im- or lacerations of the tongue, lips, buccal mucosa, palate (soft
portant for all health care providers (including dental providers) and hard), gingiva, alveolar mucosa, or frenum; fractured,
to be alert to and knowledgeable about signs and symp- displaced, or avulsed teeth; or facial bone and jaw fractures.
toms of child abuse and neglect and to know how to respond. Naidoo9 cited the lips as the most common site for inflicted
Because different communities have different resources, not oral injuries (54 percent) followed by the oral mucosa, teeth,
all providers of a certain job specification may be available gingiva, and tongue. Lacerations to the oral frena in premobile
everywhere, and thus, job roles may sometimes overlap. infants are often the result of physical abuse and are frequently
associated with other findings of serious physical abuse. 10
Physical abuse Trauma to the teeth may result in pulpal necrosis, leaving the
Craniofacial, head, face, and neck injuries occur in more than teeth gray and discolored.11,12 Gags applied to the mouth may
half of child abuse cases. 1-6 All suspected victims of abuse result in bruises, lichenification, or scarring at the corners of
or neglect, including children in state custody or foster care, the mouth.13 Some serious injuries of the oral cavity, including
should be examined carefully by the appropriate provider at posterior pharyngeal injuries and retropharyngeal abscesses,
some point during the course of the evaluation for signs of
ABBREVIATIONS
This document was originally developed in collaboration by the American Academy
of Pediatrics Committee on Child Abuse and Neglect and the American Academy AAP: American Academy of Pediatrics. ABFO: American Board of
of Pediatric Dentistry and adopted in 1 999. This is a revision of the 2005 version Forensic Odontology.
which was reaffirmed in 2010 and 2016.

may be inflicted by caregivers who fabricate illness in a child14 children.26,27 Although human papillomavirus infection may
to simulate hemoptysis or other symptoms requiring medical result in oral or perioral warts, the mode of transmission
care. All findings in cases in which there is reasonable suspi- remains uncertain. Human papillomavirus infections may be
cion of abuse or neglect, regardless of mechanism, should be transmitted sexually through oral-genital contact, vertically
reported for further investigation. Unintentional or accidental from mother to infant during birth, or horizontally through
injuries to the mouth are common and can be distinguished nonsexual contact from a child or caregiver’s hand to the
from abuse by judging whether the history (including the genitals or mouth.28,29
timing and mechanism of the injury) is consistent with the Unexplained injury or petechiae of the palate, particularly
characteristics of the injury and the child’s developmental at the junction of the hard and soft palate, may result from
capabilities. Multiple injuries, injuries in different stages of forced oral sex.30 As with all suspected child abuse or neglect,
healing, or a discrepant history should arouse suspicion for when sexual abuse is suspected or diagnosed in a child, the case
abuse. Consultation with or referral to a knowledgeable dentist must be reported to child protective services and/or law en-
or child abuse pediatrician may be helpful. The clinical report forcement agencies for investigation. 31-34 A multidisciplinary
from the American Academy of Pediatrics (AAP) entitled child abuse evaluation for the child and family is preferred
The Evaluation of Suspected Child Physical Abuse provides when available.
additional guidance.15 Children who present acutely with a recent history of sex-
ual abuse may require specialized forensic testing for semen
Sexual abuse and other foreign materials resulting from assault. Specialized
Although the oral cavity is a frequent site of sexual abuse in hospitals and child protection clinics equipped with protocols
children,16 visible oral injuries or infections are rare. When and experienced personnel are best suited for collecting such
oral-genital contact is suspected, referral to specialized clinical specimens and maintaining a chain of evidence necessary for
settings equipped to conduct comprehensive examinations investigations. If a victim provides a history for oral-penile
is recommended. The AAP clinical report entitled The Eval- contact, the buccal mucosa and tongue can be swabbed with
uation of Children in the Primary Care Setting When Sexual a sterile, cotton-tipped applicator; the swab can be air dried
Abuse Is Suspected 17 provides information regarding these and packaged appropriately for laboratory analysis.
examinations as does the Updated Guidelines for the Medical
Assessment and Care of Children Who May Have Been Sexually Bite marks
Abused18. Acute or healed bite marks may indicate abuse. Dentists
When oral-genital contact is confirmed by history or trained as forensic odontologists can assist health care pro-
examination findings, universal testing for sexually transmitted viders in the detection and evaluation of bite marks related
infections within the oral cavity is controversial; the clinician to physical and sexual abuse.35 Bite marks should be suspected
may consider risk factors (e.g., chronic abuse or a perpetrator when ecchymoses, abrasions, or lacerations are found in an
with a known sexually transmitted infection) and the child’s elliptical, horseshoe shaped, or ovoid pattern.36 Bite marks
clinical presentation when deciding whether to conduct such may have a central area of ecchymoses (contusions) caused by
testing. Accuracy to diagnose sexually transmitted infections the following two possible phenomena: (1) positive pressure
of the oral cavity is increased if evidence is collected within from the closing of the teeth with disruption of small vessels
24 hours of exposure in prepubertal children19 and within 72 or (2) negative pressure caused by suction and tongue thrust-
hours in adolescents. Evidence collection should be repeated as ing. Bites produced by dogs and other carnivorous animals
clinically indicated. Oral and perioral gonorrhea in prepubertal tend to tear flesh, whereas human bites compress flesh and
children (which is diagnosed with appropriate culture techni- can cause abrasions, contusions, and lacerations but rarely
ques and confirmatory testing) is pathognomonic of sexual avulsions of tissue. An intercanine distance (i.e., the linear
abuse but is rare.20,21 Rates are higher in sexually abused adoles- distance between the central point of the cuspid tips) measuring
cents (12 percent with gonorrhea; 14 percent with Chlamydia).22 more than 3.0 cm is suspicious for an adult human bite.37
Pharyngeal gonorrhea frequently is asymptomatic.23 Although Bite marks found on human skin are challenging to inter-
culture has been considered the gold standard, nucleic acid pret because of the distortion presented and the time elapsed
amplification tests are more commonly used now24 because they between the injury and the analysis.36 Recent investigations
are more sensitive, less invasive, and less expensive.25 Although have led to questions about the scientific validity of forensic
they have not been approved by the U.S. Food and Drug Ad- patterned evidence (bite mark analysis in particular) and its
ministration for the prepubertal age group or for rectal or role in legal proceedings.38 The pattern, size, contour, and color
oropharyngeal swab specimens, the Centers for Disease Control of a bite mark ideally can be evaluated by a forensic odon-
and Prevention does cite nucleic acid amplification tests on tologist; a forensic pathologist can be consulted if a forensic
vaginal swab specimens or urine as an alternative to cultures odontologist is not available. If neither specialist is available,
in girls. However, culture remains the preferred method for a medical provider or dental provider experienced in identi-
testing urethral swab specimens or urine for boys and for fying the patterns of child abuse injuries may examine and
extragenital swab specimens (pharynx and rectum) for all document the bite mark characteristics photographically with

an identification tag and scale marker (e.g., ruler) in the Human trafficking
photograph. The photograph should be taken such that the Human trafficking is a serious child health issue involving
angle of the camera lens is directly over the bite and in the medical and dental ramifications, among others, but it is
same plane of the bite to avoid distortion.39 A special photo- just beginning to be addressed in the United States. The U.S.
graphic scale was developed by the American Board of Forensic Department of State defines human trafficking as “[T]he
Odontology (ABFO) for this purpose as well as for docu- recruitment, harboring, transportation, provision, or obtaining
menting other patterned injuries (ABFO No. 2 Reference of a person for labor or services through the use of force,
Scale). ABFO-certified odontologists and the ABFO bite mark fraud, or coercion for the purpose of subjection to involun-
analysis flow sheet can be found on the ABFO website (www. tary servitude, peonage, debt bondage, or slavery” (22 USC
abfo.org). In addition to photographic evidence, every bite §7102[9]).48 Of these, children most commonly experience
mark that shows indentations ideally will have a polyvinyl sex trafficking, “in which a commercial sex act is induced
siloxane impression made immediately after swabbing the by force, fraud, or coercion, or in which the person induced
bite mark for secretions containing DNA. This impression will to perform such act has not attained 18 years of age” (22
help provide a three-dimensional model of the bite mark. USC §7102[9]). Sex trafficking is considered “commercial
Written observations and photographs should be repeated at sexual exploitation of children” as are pornography and sur-
intervals to best document the evolution of the bite.39 Because vival sex (defined as the exchange of sexual activity for basic
each person has a characteristic bite pattern, a forensic necessities such as shelter, food, or money).49,50
odontologist may be able to match dental models (casts) of Precise numbers of children experiencing human or sex
a suspected abuser’s teeth with impressions or photographs trafficking are difficult to obtain because of the complicated
of the bite. (This is the responsibility of the police and not nature of these definitions and underreporting. However, it is
the health care provider.) estimated that >100,000 children are victims of prostitution
DNA is present in oral epithelial cells and may be depo- each year in the United States51; see the AAP Clinical Report
sited in bites. Even if saliva and cells have dried, they can be entitled Child Sex Trafficking and Commercial Sexual Ex-
collected by using the double-swab technique. First, a sterile ploitation: Health Care Needs of Victims for more information
cotton swab moistened with distilled water is used to wipe the on identifying and serving these patients. 50 The average age
area in question, then dried and placed in a specimen tube. A of children who are exploited for sex is 12 years old, and
second control sample is collected by swabbing the victim’s children as young as 6 years old are targeted.46,51 Children who
buccal mucosa to distinguish his or her DNA from that of are or have been in foster care,49 are homeless,52 are runaways,50
the perpetrator. 39 All evidence should be collected, docu- or are incarcerated in juvenile detention facilities50 are more
mented, and labeled according to standards with a clear chain likely to be victims of human trafficking (particularly if they
of custody and submitted for forensic analysis.39 Questions are experiencing survival sex); this can include international
regarding the evidentiary procedure should be directed to a abduction, although geographical dislocation is not required
law enforcement agency. in the definition of trafficking.52
Although children who are victims of human trafficking
Bullying are often disenfranchised from most of society, more than
Thirty percent of children in the sixth to 10th grades report one-quarter of them still will see a health care professional
having been bullied and/or having bullied others.40 Children while in captivity.53 Victims of trafficking have complex psy-
with orofacial or dental abnormalities (including malocclu- chosocial and physical challenges that affect how they perceive
sion) are frequently subjected to bullying41,42 and, as a result, and respond to a given situation. Rescued victims often have
may suffer serious psychological consequences, including complex health needs, including infectious diseases, reproduc-
depression and suicidal ideation.43-45 Children who reported tive health problems, substance abuse, and mental health
physical abuse, intimate partner violence, forced sex, and problems. Dental problems also rank high in this list: for traf-
bullying were found to also report poor oral health.46 Also of ficked women and adolescents in Europe, 58 percent reported
great concern are the more subtle psychosocial consequences tooth pain.54 In the United States, more than half (54.3 percent)
that can be associated with bullying behavior. Health care of women and adolescents reported dental problems, most
providers (including dental providers) can ask patients about commonly tooth loss (42.9 percent).55 Child trafficking victims
bullying and advocate for antibullying prevention programs have twice the risk for dental problems because they “often
in schools and other community settings. 44 Health care suffer from inadequate nutrition leading to retarded growth
providers can become familiar with “Connected Kids: Safe, and poorly formed teeth, as well as dental caries, infections and
Strong, Secure,” the primary care violence prevention protocol tooth loss.”56 For older children, dental problems may trace
from the AAP that offers preventive education, screening back to their situation of origin, with limited access to or poor
for risk, and linkages to community-based counseling and quality of care. Dental problems may also come from being in
treatment resources (https://patiented.solutions.aap.org/ the trafficking situation, during which time children may have
Handout-Collection.aspx?categoryid=32034).47 had unattended problems in addition to forgone preventive
care or, even worse, physical abuse or torture to the head.54,57

Human trafficking is not a problem exclusive to girls and services. Risks and benefits of dental treatment should be
women. As many as 50 percent of victims may be boys explained, and parents should be told that appropriate anal-
or men, 58 although they are not discussed as much in the gesic and anesthetic procedures will be used to ensure the
literature. For both sexes, a commonality is a history of child’s comfort during dental procedures. If, despite these
child abuse. efforts, the parent fails to obtain therapy, the case should be
reported to the appropriate child protective services agency.62
Dental neglect
Dental neglect, as defined by the American Academy of Pedi- Conclusions
atric Dentistry, is the “willful failure of parent or guardian, It is important for health care providers (including dental
despite adequate access to care, to seek and follow through providers) to be aware that physical or sexual abuse may result
with treatment necessary to ensure a level of oral health essential in oral or dental injuries or conditions. Health care providers
for adequate function and freedom from pain and infection.”59 should be aware of when and how to document suspicious
Dental caries, periodontal diseases, and other oral conditions injuries and how to obtain laboratory evidence, photo docu-
can lead to pain, infection, loss of function, and worse if left mentation, and/or consultation with experts when appropriate.
untreated. These undesirable outcomes can adversely affect Furthermore, injuries that are inflicted by a perpetrator’s
learning, communication, nutrition, and other activities neces- mouth or teeth may leave clues regarding the timing and
sary for normal growth and development.4,60 Some children nature of the injury as well as his or her identity. Health care
who first present for dental care have severe early childhood providers should be knowledgeable about such findings, their
caries (formerly termed infant bottle or nursing caries). Care- significance, and how to meticulously observe and document
givers with adequate knowledge and willful failure to seek them. When questions arise or consultation is needed, a
care must be differentiated from caregivers without knowledge pediatric dentist or a dentist with formal training in forensic
or awareness of their child’s need for dental care when deter- odontology can ensure appropriate testing, diagnosis, and
mining the need to report such cases to child protective services. treatment.
Several factors are considered necessary for the diagnosis of Pediatric dentists and oral and maxillofacial surgeons,
neglect61: whose advanced education programs include a mandated
• a child is harmed or at risk for harm because of lack child abuse curriculum, can provide valuable information and
of dental health care; assistance to other health care providers about oral and dental
• the recommended dental care offers significant net aspects of child abuse and neglect. The Prevent Abuse and
benefit to the child; Neglect through Dental Awareness65 coalition (http://www.
• the anticipated benefit of the dental treatment is signi- healthy.arkansas.gov/programsServices/oralhealth/Pages/PANDA.
ficantly greater than its morbidity, so parents would aspx), which has trained thousands of physicians, nurses,
choose treatment over nontreatment; teachers, child care providers, dentists and other dental pro-
• access to health care is available but not used; and viders, is another resource for physicians seeking information
• the parent understands the dental advice given. on this issue. Physician members of multidisciplinary child
abuse and neglect teams are encouraged to identify such dental
Failure to seek or obtain proper dental care may result providers in their communities to serve as consultants for
from factors such as family isolation, lack of finances, trans- these teams. In addition, medical providers with experience
portation difficulty, parental ignorance, or lack of perceived or expertise in child abuse and neglect can make themselves
value of oral health. 62-64 The point at which to consider a available to dentists and dental organizations as consultants
parent negligent and begin intervention occurs after the parent and educators. Such efforts will strengthen our ability to
has been properly alerted by a health care provider about the prevent and detect child abuse and neglect and enhance our
nature and extent of the child’s condition, the specific treat- ability to care for and protect children.
ment needed, and the mechanism of accessing that treatment.62
Because many families face challenges in accessing dental Recommendations
care or insurance for their children, the health care provider, 1. Health care providers (including dental providers) are
including the dental provider, will evaluate whether dental required to report injuries that are concerning for abuse
services are readily available and accessible to the child when or neglect to child protective services in accordance
considering whether negligence has occurred. A child’s social, with local or state legal requirements. Abusive injuries
emotional, and medical ability to undergo treatment also frequently involve the face and oral cavity and, thus,
should be considered when determining dental neglect.64 may be first encountered by dental providers.
To the best of his or her ability, the health care provider 2. Similarly, sexual abuse may involve the mouth, even
should be certain that the caregiver understands the expla- without overt signs, and thus, health care providers
nation of the disease and its implications and, when barriers to (including dental providers) should know how to collect
the needed care exist, attempt to assist the family in finding a history to elicit this information as well as how to
financial aid, transportation, or public facilities for needed appropriately collect laboratory tests to support forensic

investigations. The general provider is encouraged to 8. Thompson LA, Tavares M, Ferguson-Young D, Ogle O,
become aware of and consult with appropriate special- Halpern LR. Violence and abuse: core competencies for
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3. Bite marks found on human skin are challenging to 9. Naidoo S. A profile of the oro-facial injuries in child
interpret because of the distortion presented and the physical abuse at a children’s hospital. Child Abuse Negl
time elapsed between the injury and the analysis. Ideally, 2000;24(4):521-34.
the pattern, size, contour, and color of the bite mark 10. Maguire S, Hunter B, Hunter L, et al. Diagnosing abuse:
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one is available. injuries [published correction appears in Arch Dis Child
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56. Crane PA, Moreno M. Human trafficking: what is the 64. Bhatia SK, Maguire SA, Chadwick BL, et al. Character-
role of the health care provider? J Appl Res Child 2011; istics of child dental neglect: A systematic review. J Dent
2(1):article 7. Available at: “http://digitalcommons. 2014;42(3):229-39.
library.tmc.edu/childrenatrisk/vol2/iss1/7”. Accessed 65. Arkansas Department of Health Prevent Abuse and
May 23, 2016. Neglect through Dental Awareness: The P.A.N.D.A.
57. Dovydaitis T. Human trafficking: the role of the health Coalition. Available at: “http://www.healthy.arkansas.
care provider. J Midwifery Womens Health 2010;55(5): gov/programsServices/oralhealth/Pages/PANDA.aspx”.
462-7. Accessed May 13, 2016.

BEST PRACTICES: FLUORIDE THERAPY
Fluoride Therapy
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Fluoride
2018 therapy. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
Purpose to designate fluoride simply as systemic or topical. Fluoride

The American Academy of Pediatric Dentistry intends that is swallowed, such as fluoridated water and dietary
these recommendations to help practitioners and parents supplements, may contribute to a topical effect on erupted
make decisions concerning appropriate use of fluoride teeth (before swallowed, as well as a topical effect due to
as part of the comprehensive oral health care for infants, increasing salivary and gingival crevicular fluoride levels).
children, adolescents, and persons with special health care Additionally, elevated plasma fluoride levels can treat the outer
needs. surface of fully mineralized, but unerupted, teeth topically.
Similarly, topical fluoride that is swallowed may have a
Methods systemic effect.12
This document was developed by the Liaison with Other Fluoridation of community drinking water is the most
Groups Committee and adopted in 1967. These recommen- equitable and cost-effective method of delivering fluoride to
dations by the Council of Clinical Affairs are a revision of all members of most communities.13 Water fluoridation at the
the previous version, last revised in 2014. To update this level of 0.7-1.2 milligrams fluoride ion per liter (i.e., parts
guidance, an electronic search of the scientific literature from per million fluoride [ppm F]) was introduced in the U.S. in
2012 to 2017 regarding the use of systemic and topical the 1940s. Since fluoride from water supplies is now one of
fluoride was completed. Database searches were conducted several sources of fluoride, the Department of Health and
using the terms: fluoride caries prevention, fluoridation, Human Services has recommended not having a fluoride range,
fluoride gel, fluoride varnish, fluoride toothpaste, fluoride but rather to standardize all water to the 0.7 ppm F level. The
therapy, and topical fluoride. Because 720 papers were rationale is to balance the benefits of preventing dental caries
identified through these electronic searches, an alternate while reducing the chance of fluorosis.1
strategy of limiting the information gathering to systematic Community water fluoridation has been associated with
review using the term fluoride caries prevention yielded 95 the decline in caries prevalence in U.S. adolescents, from 90
papers since 2012. Nine well-conducted systematic reviews1-9 percent in at least one permanent tooth in 12-17 years-olds
and their references primarily were used for this update. in the 1960s, to 60 percent in a 1999-2004 survey.14 When
Expert opinions and clinical practices also were relied upon used appropriately, fluoride is both safe and effective in
for these recommendations. preventing and controlling dental caries. Although adverse
health effects (e.g., decreased cognitive ability, endocrine
Background disruption and cancer) have been ascribed to the use of
Fluoride has been a major factor in the decline in prevalence fluoride over the years, the preponderance of evidence from
and severity of dental caries in the U.S. and other econo- large cohort studies and systematic reviews does not support
mically developed countries. It has several caries-protective an association of such health issues and consumption of fluo-
mechanisms of action. Topically, low levels of fluoride in ridated water.1 Regarding cognitive ability, a recent study of
plaque and saliva inhibit the demineralization of sound mothers’ urinary fluoride levels and their child’s intelligence
enamel and enhance the remineralization of demineralized quotient (IQ) levels suggested an association with exposure
enamel. Fluoride also inhibits dental caries by affecting the levels greater than those recommended in the U.S. for water
metabolic activity of cariogenic bacteria. 10 High levels of fluoridation.15 However, a prospective study in New Zealand
fluoride, such as those attained with the use of topical gels did not support an association between fluoridated water
or varnishes, produce a temporary layer of calcium fluoride- and IQ measurements, 16 and a national sample in Sweden
like material on the enamel surface. The fluoride is released found no relationship between fluoride levels in water supplies
when the pH drops in response to acid production and be- and cognitive ability, non-cognitive ability, and education.17
comes available to remineralize enamel or affect bacterial
metabolism.11 The original belief was that fluoride’s primary
action was to inhibit dental caries when incorporated into ABBREVIATIONS
developing dental enamel (i.e., the systemic route), but the IQ: Intelligence quotient. NaFV: Sodium fluoride varnish. ppm F:
fluoride concentration in sound enamel does not fully explain parts per million fluoride. SDF: Silver diamine fluoride.
the marked reduction in dental caries. It is oversimplification

one year intervals, also are efficacious in reducing caries in

Table. DIETARY FLUORIDE SUPPLEMENTATION SCHEDULE permanent teeth.27 Some topical fluoride gel and foam prod-
Age <0.3 ppm F 0.3 to 0.6 ppm F >0.6 ppm F ucts are marketed with recommended treatment times of less
than four minutes, but there are no clinical trials showing
Birth to 6 months 0 0 0 efficacy of shorter than four-minute application times.28 There
6 mo to 3 years 0.25 mg 0 0 also is limited evidence that topical fluoride foams are efficacious
3 to 6 years 0.50 mg 0.25 mg 0 in children.2 Children at risk for caries should receive a profes-
sional fluoride treatment at least every six months.28
6 to at least 16 years 1.00 mg 0.50 mg 0
Silver diamine fluoride ([SDF]; 5 percent F 44,800 ppm
F) recently has been approved by the U.S. Food and Drug
Administration and currently is used most frequently to arrest
Consumption of fluoride during the mineralization of teeth, dentinal caries. SDF arrests caries by the antibacterial effect
however, can cause fluorosis (children 1-3 years of age being of silver and by remineralization of enamel and dentin.9 Some
most susceptible for fluorosis of the permanent incisors). clinical trials show a caries arrest rate greater than 80 percent,7
The National Health and Nutrition Examination Survey but such studies have a high risk of bias and a wide variation
1999-2004 study found 23 percent of the U.S. population of results, leading to conditional recommendations at this
had very mild or mild fluorosis.18 Decisions concerning the time.29 Although the product is highly concentrated, less than
administration of fluoride are based on the unique needs a drop is needed to treat several caries lesions. The only re-
of each patient, including the risks and benefits (e.g., risk ported side effects of SDF are that caries lesions stain black
of mild or moderate fluorosis versus the benefits of decreasing after treatment, and it will temporarily stain skin with contact.
caries increment and, in some cases preventing, devastating Home use of fluoride products for children should focus
dental disease). on regimens that maximize topical contact, in lower-dose
Fluoride supplements also are effective in reducing pre- higher-frequency approaches.30 Meta-analyses of more than
valence of dental caries and should be considered for children 70 randomized or quasi-randomized controlled clinical trials
at high caries risk who drink fluoride-deficient (less than show that fluoride toothpaste is efficacious in reducing pre-
0.6 ppm F) water 19 (see Table). Determination of dietary valence of dental caries in permanent teeth, with the effect
fluoride before prescribing supplements can help reduce increased in children with higher baseline level of caries
intake of excess fluoride. Sources of dietary fluoride may with higher concentration of fluoride in the toothpaste,
include drinking water from home, day care, and school; greater frequency of use, and supervision of brushing. 31,32 A
beverages such as soda 20, juice21, and infant formula 22; pre- meta-analysis of eight clinical trials on caries increment in
pared food23; and toothpaste. Concentrated infant formulas preschool children also shows that tooth brushing with fluo-
requiring reconstitution with water have raised concerns ridated toothpaste significantly reduces dental caries prevalence
regarding an increased risk of fluorosis. 24 Infants may be in the primary dentition.6 Using no more than a smear or
particularly susceptible because of the large consumption of rice-size amount of fluoridated toothpaste for children less
such liquid in the first year of life, while the body weight than three years of age may decrease risk of fluorosis. Using
is relatively low. 12 An evidence-based review found that no more than a pea-size amount of fluoridated toothpaste is
consumption of reconstituted infant formula can be associated appropriate for children aged three to six8 (see Figure). To
with an increased risk of mild fluorosis, but recommended maximize the beneficial effect of fluoride in the toothpaste,
the continued use of fluoridated water. 25 One study has supervised tooth-brushing should be done twice a day and
shown that dental fluorosis levels do not vary in fluoridated rinsing after brushing should be kept to a minimum or
areas regardless of premixed versus reconstituted formula.26 eliminated altogether.4 Other topical fluoride products (e.g.,
Standardization of the optimal fluoride levels in drinking
water to 0.7 ppm F, however, makes this issue moot.
Professionally-applied topical fluoride treatments are
efficacious in reducing prevalence of dental caries. The most
commonly used agents for professionally-applied fluoride
treatments are five percent sodium fluoride varnish ([NaFV]
2.26 percent F, 22,600 ppm F) and acidulated phosphate
fluoride ([APF]; 1.23 percent F, 12,300 ppm F). Meta-analyses
of 23 clinical trials, most with twice yearly application,
favors the use of fluoride varnish in primary and permanent
teeth.2 Unit doses of fluoride varnish are the only professional
topical fluoride agent that are recommended for children
younger than age six.2 Meta-analyses of placebo-controlled Figure. Comparison of a smear (left) with a pea-sized (right) amount
trials show that fluoride gels, applied at three months to of toothpaste.

prescription-strength home-use 0.5 percent fluoride gels 4. Scottish Intercollegiate Guideline Network, Dental
and pastes; prescription-strength, home-use 0.09 percent interventions to prevent caries in children. March 2014.
fluoride mouthrinse) have benefit in reducing dental caries Available at: “www.sign.ac.uk/assets/sign138.pdf ”.
in children six years or older.2 Acccessed October 10, 2017. (Archived by WebCite®
at: “http://www.webcitation.org/6xE7Ay0oY”)
Recommendations 5. Chou R, Cantor A, Zakher B, Mitchell JP, Pappas M.
1. There is confirmation from evidence-based reviews Prevention of Dental Caries in Children Younger Than
that fluoride use for the prevention and control of 5 Years Old: Systematic Review to Update the U.S. Pre-
caries is both safe and highly effective in reducing ventive Services Task Force Recommendation. Evidence
dental caries prevalence. Synthesis No. 104. AHRQ Publication No. 12-05170-
2. There is support from evidence-based reviews that EF-1. Rockville, Md.: Agency for Healthcare Research
fluoride dietary supplements are effective in reducing and Quality; 2014.
dental caries and should be considered for children 6. Santos APP, Nadanovsky P, Oliveira BH. A systematic
at caries risk who drink fluoride-deficient (less than review and meta-analysis of the effects of fluoride tooth-
0.6 ppm) water. paste on the prevention of dental caries in the primary
3. There is support from evidenced-based reviews that dentition of preschool children. Community Dent Oral
professionally applied topical fluoride treatments as five Epidemiol 2013;41(1):1-12.
percent NaFV or 1.23 percent F gel preparations are 7. Gao SS, Zhao IS, Hiraishi N, et al. Clinical trials of silver
efficacious in reducing caries in children at caries risk. diamine fluoride in arresting caries among children: A
4. There is support from evidence-based reviews that systematic review. Int Amer Assoc Dent Res 2016;1(3):
fluoridated toothpaste is effective in reducing dental 201-10.
caries in children with the effect increased in chil- 8. Wright JT, Hanson N, Ristic H, et al. Fluoride tooth-
dren with higher baseline level of caries, higher con- paste efficacy and safety in children younger than 6
centration of fluoride in the toothpaste, greater years. J Am Dent Assoc 2014;145(2):182-9.
frequency in use, and supervision. Using no more than 9. Zhao IS, Gao SS, Hiraishi N, et al. Mechanisms of silver
a smear or rice-size amount of fluoridated toothpaste diamine fluoride on arresting caries: A literature review.
for children less than three years of age may decrease Int Dent J 2018;68(2):67-76.
risk of fluorosis. Using no more than a pea-size 10. Buzalaf MA, Pessan JP, Honório HM, ten Cate JM.
amount of fluoridated toothpaste is appropriate for Mechanism of action of fluoride for caries control.
children aged three to six. Monogr Oral Sci 2011;22:97-114.
5. There is support from evidenced-based reviews that 11. Center for Disease Control and Prevention. Recom-
prescription-strength home-use 0.5 percent fluoride mendations for using fluoride to prevent and control
gels and pastes and prescription-strength home-use dental caries in the United States. MMWR Recomm
0.09 percent fluoride mouthrinse also are effective Rep 2001;50(RR-14):1-42.
in reducing dental caries. 12. Tinanoff N. Use of fluoride. In: Berg J, Slayton RA, eds.
6. There is support from evidence-based reviews to Early Childhood Oral Health. 2nd ed. Hoboken, N.J.:
recommend the use of 38 percent silver diamine Wiley-Blackwell; 2016:104-19.
fluoride for the arrest of cavitated caries lesions in 13. Division of Oral Health, National Center for Chronic
primary teeth as part of a comprehensive caries man- Disease Prevention and Health Promotion, Center for
agement program. Disease Control and Prevention. Achievements in public
health, 1900-1999; Fluoridation of drinking water to
References prevent dental caries. JAMA 2000;283(10):1283-6.
1. U.S. Department of Health and Human Services Panel 14. U.S. Department of Health and Human Services. Pro-
on Community Water Fluoridation. U.S. Public Health posed HHS recommendation for fluoride concentration
Services recommendation for fluoride concentration in drinking water for prevention of dental caries. Federal
in drinking water for the prevention of dental caries. register 2011;76(9):2383-8.
Public Health Reports 2015;130(5):1-14. 15. Bashash M, Thomas D, Hu H, et al. Prenatal fluoride
2. Weyant RJ, Tracy SL, Anselmo T, et al. Topical fluoride exposure and cognitive outcomes in children at 4 and
for caries prevention: Executive summary of the updated 6–12 years of age in Mexico. Environmental Health
clinical recommendations and supporting systematic Perspective, 2017. Available at: “https://208doi.org/10.
review. J Amer Dent Assoc 2013;144(11):1279-91. 1289/EHP655”. Accessed October 10, 2017. (Archived
3. Lenzi TL, Montagner A, Soares FLM, et al. Are topical by WebCite ® at: “http://www.webcitation.org/6xE7
fluorides effective for treating incipient carious lesions: OtaW3”)
A systematic review and meta-analysis. J Am Dent Assoc
2016;147(2):84-92.e1.

16. Broadbent JM, Thomson WM, Ramrakha S, et al. Com- 25. Berg J, Gerweck C, Hujoel PP, et al. Evidence-based
munity water fluoridation and intelligence: Prospective clinical recommendations regarding fluoride intake from
study in New Zealand. Am J Public Health 2015;105 reconstituted infant formula and enamel fluorosis. J Am
(1):72-6. Dent Assoc 2011;142(1):79-87.
17. Aggeborn L, Öhman M. The effects of fluoride in the 26. Do LG, Levy SM, Spencer AJ. Association between
drinking water. 2016. Available at: “https://sites.google. infant formula feeding and dental fluorosis and caries in
com/site/linuzaggeborn/aggeborn-ohman-20161103.pdf? Australian children. J Public Health Dent 2012;72(2):
attredirects=1”. Accessed October. 10, 2017. (Archived by 112-21.
WebCite® at: “http://www.webcitation.org/6xE7YwKhd”) 27. Marinho VC, Higgin JP, Logan, S, Sheiham A. System-
18. Beltrán-Aguilar ED, Barker L, Dye BA. Prevalence and atic review of controlled trials on the effectiveness of
severity of dental fluorosis in the United States, 1999- fluoride gels for the prevention of dental caries in chil-
2004, NCHS Data Brief No. 53; 2010:1-8. dren. J Dent Ed 2003;67(4):448-58.
19. Rozier RG, Adair S, Graham F, et al. Evidence-based 28. Hunter JW, Chan JT, Featherstone DB, et al.
clinical recommendations on the prescription of dietary Professionally-applied topical fluoride: Evidence-based
fluoride supplements for caries prevention: A report of clinical recommendations. J Am Dent Assoc 2006;137
the American Dental Association Council on Scientific (8):1151-9.
Affairs. J Am Dent Assoc 2010;141(12):1480-9. 29. Crystal YO, Marghalani AA, Ureles SD, et al. Use of
20. Heilman JR, Kiritsy MC, Levy SM, Wefel JS. Assessing silver diamine fluoride for dental caries management in
fluoride levels of carbonated soft drinks. J Am Dent children and adolescents, including those with special
Assoc 1999;130(11):1593-9. health care needs. Pediatr Dent 2017;39(5):E135-E145.
21. Kiritsy MC, Levy SM, Warren JJ, Guha-Chowdhury 30. Adair SM. Evidence-based use of fluoride in contem-
N, Heilman JR, Marshall T. Assessing fluoride concen- porary pediatric dental practice. Pediatr Dent 2006;28
trations of juices and juice-flavored drinks. J Am Dent (2):133-42.
Assoc 1996;127(7):895-902. 31. Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride
22. Levy SM, Kohout FJ, Guha-Chowdhury N, Kiritsy toothpaste for preventing dental caries in children and
MC, Heilman JR, Wefel JS. Infants’ fluoride intake from adolescents. Cochrane Database of Sys Rev 2003;(1):
drinking water alone, and from water added to formula, CD002278.
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23. Heilman JR, Kiritsy MC, Levy SM, Wefel JS. Fluoride Marinho VC, Shi X. Fluoride toothpastes of different
concentrations of infant foods. J Am Dent Assoc 1997; concentrations for preventing dental caries in children
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24. Hujoel PP, Zina LG. Moimas SAS, Cunha-Cruz J. Infant (1):CD007868.
formula and enamel fluorosis. A systematic review. J Am
Dent Assoc 2009;140(7):841-54.

BEST PRACTICES: BEHAVIOR GUIDANCE
Behavior Guidance for the Pediatric Dental Patient

Latest Revision How to Cite: American Academy of Pediatric Dentistry. Behavior
2020 guidance for the pediatric dental patient. The Reference Manual
Dentistry; 2020:292-310.
Purpose Background
The American Academy of Pediatric Dentistry (AAPD) Dental practitioners are expected to recognize and effectively
recognizes that dental care is medically necessary for the pur- treat childhood dental diseases that are within the knowledge
pose of preventing and eliminating orofacial disease, infection, and skills acquired during their professional education. Safe
and pain, restoring the form and function of the dentition, and effective treatment of these diseases requires an under-
and correcting facial disfiguration or dysfunction.1 Behavior standing of and, at times, modifying the child’s and family’s
guidance techniques, both nonpharmalogical and pharma- response to care. Behavior guidance a continuum of interaction
logical, are used to alleviate anxiety, nurture a positive dental involving the dentist and dental team, the patient, and parent
attitude, and perform quality oral health care safely and directed toward communication and education, while also
efficiently for infants, children, adolescents, and persons with ensuring the safety of both oral health professionals and the
special health care needs (SHCN). Selection of techniques must child, during the delivery of medically necessary care. Goals
be tailored to the needs of the individual patient and the skills of behavior guidance are to: 1) establish communication, 2)
of the practitioner. The AAPD offers these recommendations alleviate the child’s dental fear and anxiety, 3) promote pa-
to inform health care providers, parents, and other interested tient’s and parents’ awareness of the need for good oral health
parties about influences on the behavior of pediatric dental and the process by which it is achieved, 4) promote the child’s
patients and the many behavior guidance techniques used in positive attitude toward oral health care, 5) build a trusting
contemporary pediatric dentistry. Information regarding pain relationship between dentist/staff and child/parent, and 6)
management, protective stabilization, and pharmacological provide quality oral health care in a comfortable, minimally-
behavior management for pediatric dental patients is provided restrictive, safe, and effective manner. Behavior guidance tech-
in greater detail in additional AAPD best practices documents.2-6 niques range from establishing or maintaining communication
to stopping unwanted or unsafe behaviors.13 Knowledge of
Methods the scientific basis of behavior guidance and skills in com-
Recommendations on behavior guidance were developed munication, empathy, tolerance, cultural sensitivity, and
by the Clinical Affairs Committe, Behavior Management flexibility are requisite to proper implementation. Behavior
Subcommittee and adopted in 1990.7 This document by the guidance should never be punishment for misbehavior, power
Council of Clinical Affairs is a revision of the previous version, assertion, or use of any strategy that hurts, shames, or belittles
last revised in 2015.8 The original guidance was developed a patient.
subsequent to the AAPD’s 1988 conference on behavior
management and modified following the AAPD’s symposia Predictors of child behaviors
on behavior guidance in 2003 10 and 2013.11 This update Patient attributes
reflects a review of the most recent proceedings, other dental A dentist who treats children should be able to accurately
and medical literature related to behavior guidance of the pedi- assess the child’s developmental level, dental attitudes, and
atric patient, and sources of recognized professional expertise temperament to anticipate the child’s reaction to care. The
and stature including both the academic and practicing response to the demands of oral health care is complex and
pediatric dental communities and the standards of the American determined by many factors.
Dental Association Commission on Dental Accreditation.12 In Factors that may contribute to noncompliance during the
®
addition, a search of the PubMed /MEDLINE electronic
database was performed, (see Appendix 1 after References).
dental appointment include fears, general or situational
anxiety, a previous unpleasant and/or painful dental/medical
Articles were screened by viewing titles and abstracts. Data was
abstracted and used to summarize research on behavior
ABBREVIATIONS
guidance for infants and children through adolescents, includ- AAPD: American Academy of Pediatric Dentistry. AAT: Animal-
ing those with special healthcare needs. When data did not assisted therapy. ITR: Interim therapeutic restoration. PECS: Picture
appear sufficient or were inconclusive, recommendations were exchange communication system. SADE: Sensory-adapted dental
based upon expert and/or consensus opinion by experienced environment. SDF: Silver diamine fluoride. SHCN: Special health-
care needs.
researchers and clinicians.

experience, pain, inadequate preparation for the encounter, for the child’s response to care (e.g., no tears) are unrealistic,
and parenting practices.13-19 In addition, cognitive age, devel- while expectations for the dentist who guides their behavior
opmental delay, inadequate coping skills, general behavioral are great.19
considerations, negative emotionality, maladaptive behaviors,
physical/mental disability, and acute illness or chronic disease Orientation to dental environment
are potential reasons for noncompliance during the dental The non-clinical office staff plays an important role in
appointment.13-19 behavior guidance. The scheduling coordinator or receptionist
Dental behavior management problems often are more often will be the first point of contact with a prospective
readily recognized than dental fear/anxiety due to associations patient and family, either through the internet or a telephone
with general behavioral considerations (e.g., activity, impul- conversation. The tone of the communication should be wel-
sivity) versus temperamental traits (e.g., shyness, negative coming. The scheduling coordinator or receptionist should
emotionality) respectively. 20 Only a minority of children actively engage the patient and family to determine their
with uncooperative behavior have dental fears, and not all primary concerns, chief complaint, and any special health care
fearful children present with dental behavior guidance prob- or cultural/linguistic needs. The communication can provide
lems.14,21,22 Fears may occur when there is a perceived lack of insights into patient or family anxiety or stress. Staff should
control or potential for pain, especially when a child is aware help set expectations for the initial visit by providing relevant
of a dental problem or has had a painful healthcare experience. information and may suggest a pre-appointment visit to the
If the level of fear is incongruent with the circumstances and office to meet the doctor and staff and tour the facility.20 The
the patient is not able to control impulses, disruptive behavior non-clinical staff should confirm the office’s location, offer
is likely.20 directions, and ask if there are any further questions. Such
Cultural and linguistic factors also may play a role in patient encounters serve as educational tools that help to allay fears
cooperation and selection of behavior guidance techniques.23-26 and better prepare the family and patient for the first visit.
Since every culture has its own beliefs, values, and practices, The parent’s/patient’s initial contact with the dental practice
it is important to understand how to interact with patients allows both parties to address the child’s primary oral health
from different cultures and to develop tools to help navigate needs and to confirm the appropriateness of scheduling an
their encounters. Translation services should be made available appointment.33 From a behavioral standpoint, many factors
for those families who have limited English proficiency. 26,27 are important when appointment times are determined. 20
A federal mandate requires translation services for non-English Appointment-related concerns include patient age, presence
speaking families be available at no cost to the family in of a special health care need, the need for sedation, distance
healthcare facilities that receive federal funding for services.28 the parent/patient travels, length of appointment, additional
As is true for all patients/families, the dentist/staff must staffing requirements, parent’s work schedule, and time of day.
listen actively and address the patient’s/parents’ concerns in a Emergent or urgent treatment should not be delayed on these
sensitive and respectful manner.23 grounds alone.34 Appointment scheduling should be tailored
to the needs of the individual patient’s circumstances and the
Parental influences skills of the practitioner. The practitioner should formulate
Parents influence their child’s behavior at the dental office in a policy regarding scheduling, and scheduling should not
several ways. Positive attitudes toward oral health care may be left to chance. 20 Appointment duration should not be
lead to the early establishment of a dental home. Early pre- prolonged beyond a patient’s tolerance level solely for the
ventive care leads to less dental disease, decreased treatment practitioner’s convenience. 20 Consideration of appointment
needs, and fewer opportunities for negative experiences.29,30 scheduling will benefit the parent/patient and practitioner by
Parents who have had negative dental experiences as a patient building a trusting relationship that promotes the patient’s
may transmit their own dental anxiety or fear to the child positive attitude toward oral health care.
thereby adversely affecting her attitude and response to Reception staff are usually the first team members the
care. 14,17,31,32 Long term economic hardship leads to stress, patient meets upon arrival at the office. The caring and assuring
which can lead to parental adjustment problems such as de- manner in which the child is welcomed into the practice
pression, anxiety, irritability, substance abuse, and violence.23 at the first and subsequent visits is important. 19,35 A child-
Parental depression may result in parenting changes, including friendly reception area (e.g., age-appropriate toys and games)
decreased supervision, caregiving, and discipline for the child, can provide a distraction for and comfort young patients.
thereby placing the child at risk for a wide variety of adjust- These first impressions may influence future behaviors.
ment issues including emotional and behavior problems.23 In
America, evolving parenting styles17,18 and parental behaviors Patient assessment
influenced by economic hardship have left practitioners An evaluation of the child’s cooperative potential is essential
challenged by an increasing number of children ill-equipped for treatment planning. No single assessment method or tool
with the coping skills and self-discipline necessary to contend is completely accurate in predicting a patient’s behavior, but
with new experiences.23,24,26 Frequently, parental expectations awareness of the multiple influences on a child’s response to

care can aid in treatment planning.36 Initially, information can Communication may be impaired when the sender’s expres-
be gathered from the parent through questions regarding the sion and body language are not consistent with the intended
child’s cognitive level, temperament/personality characteris- message. When body language conveys uncertainty, anxiety,
tics,15,22,37,38,39 anxiety and fear,14,22,40 reaction to strangers,41 or urgency, the dentist cannot effectively communicate con-
and behavior at previous medical/dental visits, as well as how fidence or a calm demeanor.45
the parent anticipates the child will respond to future dental In addition, the operatory may contain distractions (e.g.,
treatment. Later, the dentist can evaluate cooperative potential another child crying) that, for the patient, produce anxiety
by observation of and interaction with the patient. Whether and interfere with communication. Dentists and other mem-
the child is approachable, somewhat shy, or definitely shy bers of the dental team may find it advantageous to discuss
and/or withdrawn may influence the success of various com- certain information (e.g., post-operative instructions,
municative techniques. Assessing the child’s development, preventive counseling) away from the operatory and its many
past experiences, and current emotional state allows the distractions.19
dentist to develop a behavior guidance plan to accomplish the The communicative behavior of dentists is a major factor
necessary oral health care.20 During delivery of care, the dentist in patient satisfaction.46,47 Dentist actions that are reported to
must remain attentive to physical and/or emotional indicators correlate with low parent satisfaction include rushing through
of stress.23-26,42 Changes in behaviors may require alterations appointments, not taking time to explain procedures, barring
to the behavioral treatment plan. parents from the examination room, and generally being
impatient.37,43 However, when a provider offers compassion,
Dentist/dental team behaviors empathy, and genuine concern, there may be better acceptance
The behaviors of the dentist and dental staff members are the of care.43 While some patients may express a preference for a
primary tools used to guide the behavior of the pediatric provider of a specific gender, female and male practitioners
patient. The dentist’s attitude, body language, and communi- have been found to treat patients and parents in a similar
cation skills are critical to creating a positive dental visit for manner.39
the child and to gain trust from the child and parent.29 Dentist The clinical staff is an extension of the dentist in behavior
and staff behaviors that can help reduce anxiety and encourage guidance. A collaborative approach helps assure that both the
patient cooperation include giving clear and specific instruc- patient and parent have a positive dental experience. All den-
tions, having empathetic communication style, and offering tal team members are encouraged to expand their skills and
verbal reassurance.43 Dentists and staff must continue to be knowledge through dental literature, video presentations, and/
attentive to their communication styles throughout interactions or continuing education courses.49
with patients and families.44
Communication (i.e., imparting or interchange of thoughts, Informed consent
opinions, or information) may occur by a number of means All behavior guidance decisions must be based on a review of
but, in the dental setting, it is accomplished primarily through the patient’s medical, dental, and social history followed by an
dialogue, tone of voice, facial expression, and body language.45 evaluation of current behavior. Decisions regarding the use
Communication between the doctor/staff and the child and of behavior guidance techniques other than communicative
parent is vital to successful outcomes in the dental office. management cannot be made solely by the dentist. They must
The four essential ingredients of communication are: involve a parent and, if appropriate, the child. The practitioner,
1. the sender, as the expert on dental care (i.e., the timing and techniques
2. the message, including the facial expression and body by which treatment can be delivered), should effectively com-
language of the sender, municate behavior and treatment options, including potential
3. the context or setting in which the message is sent, and benefits and risks, and help the parent decide what is in the
4. the receiver.46 child’s best interests. 29 Successful completion of diagnostic
and therapeutic services is viewed as a partnership of dentist,
For successful bi-directional communication to take place, parent, and child.29,50,51 The conversation should allow questions
all four elements must be present and consistent. Without from the parent and patient in order to clarify issues and to
consistency, there may be a poor fit between the intended verify the parents’ and child’s comprehension. This should be
message and what is understood.45 done in the family’s preferred language, with assistance of a
Communicating with children poses special challenges trained interpreter if needed.13,28
for the dentist and the dental team. A child’s cognitive Communicative management, by virtue of being a basic
development will dictate the level and amount of information element of communication, requires no specific consent. All
interchange that can take place.26 With a basic understanding other behavior guidance techniques require informed con-
of the cognitive development of children, the dentist can use sent consistent with the AAPD’s Best Practices on Informed
appropriate vocabulary and body language to send messages Consent52 and applicable state laws. A signature on the con-
consistent with the receiver’s intellectual development.26,45 sent form does not necessarily constitute informed consent.
Informed consent implies information was provided to the

parent, risks/benefits and alternatives were discussed, questions scale, an accompanying descriptor (e.g., “+, non-verbal”) will
were answered, and permission was obtained prior to admin- help practitioners better plan for subsequent visits.
istration of treatment.13 If the parent refuses treatment after
discussions of the risks/benefits and alternatives of the proposed Treatment deferral
treatment and behavior guidance techniques, an informed Dental disease usually is not life-threatening, and the type and
refusal form should be signed by the parent and retained in timing of dental treatment can be deferred in certain circum-
the patient’s record.53 If the dentist believes the informed re- stances. When a child’s cognitive abilities or behavior prevents
fusal violates proper standard of care, he should recommend routine delivery of oral health care using communicative
the patient seek another opinion and/or dismiss the patient guidance techniques, the dentist must consider the urgency of
from the practice.52 If the dentist suspects dental neglect54, he dental need when determining a plan of treatment.56,57 In some
is obligated to report to appropriate authorities.52,55 cases, treatment deferral may be considered as an alternative
In the event of an unanticipated behavioral reaction to to treating the patient under sedation or general anesthesia.
dental treatment, it is incumbent upon the practitioner to pro- However, rapidly advancing disease, trauma, pain, or infection
tect the patient and staff from harm. Following immediate usually dictates prompt treatment. Deferring some or all treat-
intervention to assure safety, if a new behavior guidance plan is ment or employing therapeutic interventions (e.g., silver
developed to complete care, the dentist must obtain informed diamine fluoride [SDF] 74 interim therapeutic restoration
consent for the alternative methods.52,56,57 [ITR],75,76 fluoride varnish, antibiotics for infection control)
until the child is able to cooperate may be appropriate when
Pain assessment and management during treatment based upon an individualized assessment of the risks and
Pain has a direct influence on behavior and should be assessed benefits of that option. The dentist must explain the risks and
and managed throughout treatment.58 Anxiety may be a pre- benefits of deferred or alternative treatments clearly, and
dictor of increased pain perception. 59 Findings of pain or a informed consent must be obtained from the parent.52,53,56 In
painful past health care visit are important considerations in select cases where ITR or SDF is employed, regular reevalu-
the patient’s medical/dental history that will help the dentist ations are recommended and retreatment may be needed.77,78
anticipate possible behavior problems. 2,53,58 Prevention or Treatment deferral also should be considered in cases when
reduction of pain during treatment can nurture the relation- treatment is in progress and the patient’s behavior becomes
ship between the dentist and the patient, build trust, allay fear hysterical or uncontrollable. In such cases, the dentist should
and anxiety, and enhance positive dental attitudes for future halt the procedure as soon as possible, discuss the situation
visits.60-64 Pain can be assessed using self-report, behavioral, and with the patient/parent, and either select another approach
biological measures. In addition, there are several pain assess- for treatment or defer treatment based upon the dental needs
ment instruments that can be used in patients.2 The subjective of the patient. If the decision is made to defer treatment, the
nature of pain perception, varying patient responses to painful practitioner immediately should complete the necessary steps
stimuli, and lack of use of accurate pain assessment scales may to bring the procedure to a safe conclusion before ending the
hinder the dentist’s attempts to diagnose and intervene during appointment.57,75,76
procedures.31,61,62,65-67 Observing changes in patient behavior Caries risk should be reevaluated when treatment options
(e.g., facial expressions, crying, complaining, body movement are compromised due to child behavior.79 An individualized
during treatment) as well as biologic measures (e.g., heart preventive program, including appropriate parent education
rate, sweating) (is important in pain evaluation. 2,61,64 The and a dental recall schedule, should be recommended after
patient is the best reporter of her pain. 31,62,65,66 Listening to evaluation of the patient’s caries risk, oral health needs, and
the child at the first sign of distress will facilitate assessment abilities. Topical fluorides (e.g., brush-on gels, fluoride
and any needed procedural modifications.62 At times, dental varnish, professional application during prophylaxis) may
providers may underestimate a patient’s level of pain or may be indicated. 80 ITR may be useful as both preventive and
develop pain blindness as a defense mechanism and continue therapeutic approaches.75,76
to treat a child who really is in pain.31,61,68-71 Misinterpreted or
ignored changes in behavior due to painful stimuli can cause Behavior guidance techniques
sensitization for future appointments as well as psychological Since children exhibit a broad range of physical, intellectual,
trauma.72 emotional, and social development and a diversity of attitudes
and temperament, it is important that dentists have a wide
Documentation of patient hehaviors range of behavior guidance techniques to meet the needs of
Recording the child’s behavior serves as an aid for future the individual child and be tolerant and flexible in their
appointments.66 One of the more reliable and frequently used implementation.18,25 Behavior guidance is not an application
behavior rating systems in both clinical dentistry and research of individual techniques created to deal with children, but
is the Frankl Scale.20,66,73 This scale (see Appendix 2) separates rather a comprehensive, continuous method meant to develop
observed behaviors into four categories ranging from definitely and nurture the relationship between the patient and doctor,
negative to definitely positive.20,66,73 In addition to the rating which ultimately builds trust and allays fear and anxiety. Some

of the behavior guidance techniques in this document are in- • Objectives: The objectives of positive pre-visit imagery are
tended to maintain communication, while others are intended to:
to extinguish inappropriate behavior and establish communi- — provide children and parents with visual information
cation. As such, these techniques cannot be evaluated on an on what to expect during the dental visit; and
individual basis as to validity but must be assessed within the — provide children with context to be able to ask providers
context of the child’s total dental experience. Techniques must relevant questions before dental procedures commence.
be integrated into an overall behavior guidance approach • Indications: Use with any patient.
individualized for each child. Consequently, behavior guidance • Contraindication: None.
is as much an art as it is a science.
Direct observation
Recommendations • Description: Patients are shown a video or are permitted
Basic behavior guidance to directly observe a young cooperative patient undergoing
Communication and communicative guidance dental treatment.85,86
Communicative management and appropriate use of commands • Objectives: The objectives of direct observation are to:
are applied universally in pediatric dentistry with both the — familiarize the patient with the dental setting and
cooperative and uncooperative child. At the beginning of specific steps involved in a dental procedure; and
a dental appointment, asking questions and active/reflective — provide an opportunity for the patient and parent to
listening can help establish rapport and trust.81,82 The dentist ask questions about the dental procedure in a safe
may establish teacher/student roles in order to develop an environment.
educated patient and deliver quality dental treatment safely.20,29 • Indications: Use with any patient.
Once a procedure begins, bi-directional communication • Contraindications: None.
should be maintained, and the dentist should consider the
child as an active participant in his well-being and care.83 Tell-show-do
With this two-way interchange of information, the dentist also • Description: The technique involves verbal explanations of
can provide one-way guidance of behavior through directives. procedures in phrases appropriate to the developmental
Use of self-disclosing assertiveness techniques (e.g., “I need level of the patient (tell); demonstrations for the patient of
you to open your mouth so I can check your teeth”, “I need the visual, auditory, olfactory, and tactile aspects of the
you to sit still so we can take an X-ray”) tells the child exactly procedure in a carefully defined, nonthreatening setting
what is required to be cooperative.82 The dentist can ask the (show); and then, without deviating from the explanation
child ‘yes’ or ‘no’ questions where the child can answer with and demonstration, completion of the procedure (do). The
a ‘thumbs up’ or ‘thumbs down’ response. Also, observation tell-show-do technique operates with communication skills
of the child’s body language is necessary to confirm the (verbal and nonverbal) and positive reinforcement.29,34,35,81
message is received and to assess comfort and pain level.60,61,82 • Objectives: The objectives of tell-show-do are to:
Communicative guidance comprises a host of specific tech- — teach the patient important aspects of the dental visit
niques that, when integrated, enhance the evolution of a and familiarize the patient with the dental setting and
cooperative patient. Rather than being a collection of singular armamentarium; and
techniques, communicative guidance is an ongoing subjective — shape the patient’s response to procedures through
process that becomes an extension of the personality of the desensitization and well-described expectations.
dentist. Associated with this process are the specific techniques • Indications: Use with any patient.
of pre-visit imagery, direct observation, tell-show-do, • Contraindications: None.
ask-tell-ask, voice control, nonverbal communication, positive
reinforcement, various distraction techniques (e.g., audio, Ask-tell-ask
visual, imagination, thoughtful designs of clinic), memory • Description: This technique involves inquiring about the
restructuring desensitization to dental setting and procedures, patient’s visit and feelings toward or about any planned
parental presence/absence, enhanced control, additional procedures (ask); explaining the procedures through dem-
considerations for patients with anxiety or SHCN and nitrous onstrations and non-threatening language appropriate to
oxide/oxygen inhalation. 81 The dentist should consider the the cognitive level of the patient (tell); and again inquiring
development of the patient, as well as the presence of other if the patient understands and how she feels about the
communication deficits (e.g., hearing disorder), when impending treatment (ask). If the patient continues to have
choosing specific communicative guidance techniques. concerns, the dentist can address them, assess the situation,
and modify the procedures or behavior guidance techniques
Positive pre-visit imagery if necessary.26
• Description: Patients preview positive photographs or • Objectives: The objectives of ask-tell-ask are to:
images of dentistry and dental treatment before the dental — assess anxiety that may lead to noncompliant behavior
appointment.84 during treatment;

— teach the patient about the procedures and their imple- music) and/or visual (e.g., television, virtual reality eye-
mentation; and glasses) effects.81,88 Giving the patient a short break during
— confirm the patient is comfortable with the treatment a stressful procedure can be an effective use of distraction
before proceeding. before considering more advanced behavior guidance
• Indications: Use with any patient able to dialogue. techniques.20,45,87
• Contraindications: None. • Objectives: The objectives of distraction are to:
— decrease the perception of unpleasantness; and
Voice control — avert negative or avoidance behavior.
• Description: Voice control is a deliberate alteration of voice • Indications: Use with any patient.
volume, tone, or pace to influence and direct the patient’s • Contraindications: None.
behavior. While a change in cadence may be readily ac-
cepted, use of an assertive voice may be considered aversive Memory restructuring
to some parents unfamiliar with this technique. An explana- • Description: Memory restructuring is a behavioral approach
tion before its use may prevent misunderstanding.20,29,34,35 in which memories associated with a negative or difficult
• Objectives: The objectives of voice control are to: event (e.g., first dental visit, local anesthesia, restorative pro-
— gain the patient’s attention and compliance; cedure, extraction) are restructured into positive memories
— avert negative or avoidance behavior; and using information suggested after the event has taken place.89
— establish appropriate adult-child roles. This approach was utilized with children who received local
• Indications: Use with any patient. anesthesia at an initial restorative dental visit and showed
• Contraindications: Patients who are hearing impaired. a change in local anesthesia-related fears and behaviors at
subsequent treatment visits.89,90 Restructuring involves four
Nonverbal communication components: (1) visual reminders; (2) positive reinforcement
• Description: Nonverbal communication is the reinforcement through verbalization; (3) concrete examples to encode
and guidance of behavior through appropriate contact, sensory details; and (4) sense of accomplishment. A visual
posture, facial expression, and body language.29,34,35,51,81 reminder could be a photograph of the child smiling at the
• Objectives: The objectives of nonverbal communication are to: initial visit (i.e., prior to the difficult experience). Positive
— enhance the effectiveness of other communicative reinforcement through verbalization could be asking if the
guidance technique; and child had told her parent what a good job she had done at
— gain or maintain the patient’s attention and compliance. the last appointment. The child is asked to role-play and
• Indications: Use with any patient. to tell the dentist what she had told the parent. Concrete
• Contraindications: None. examples to encoding sensory details include praising the
child for specific positive behavior such as keeping her hands
Positive reinforcement and descriptive praise on her lap or opening her mouth wide when asked. The child
• Description: In the process of establishing desirable patient then is asked to demonstrate these behaviors, which leads to
behavior, it is essential to give appropriate feedback. a sense of accomplishment.
Positive reinforcement rewards desired behaviors thereby • Objectives: The objectives of memory restructuring are to:
strengthening the likelihood of recurrence of those behav- — restructure difficult or negative past dental experiences;
iors. Social reinforcers include positive voice modulation, and
facial expression, verbal praise, and appropriate physical — improve patient behaviors at subsequent dental visits.
demonstrations of affection by all members of the dental • Indications: Use with patients who had a negative or
team. Descriptive praise emphasizes specific cooperative difficult dental visits.
behaviors (e.g., “Thank you for sitting still”, “You are doing • Contraindications: None.
a great job keeping your hands in your lap”) rather than a
generalized praise (e.g., “Good job”).82 Nonsocial reinforcers Desensitization to dental setting and procedures
include tokens and toys. • Description: Systematic desensitization is a psychological
• Objective: The objective of positive reinforcement and technique that can be applied to modify behaviors of
descriptive praise is to reinforce desired behavior.20,34,45,81,87 anxious patients in the dental setting.91 It is a process that
• Indications: Use with any patient. diminishes emotional responsiveness to a negative, aversive,
• Contraindications: None. or positive stimulus after progressive exposure to it. Patients
are exposed gradually through a series of sessions to compo-
Distraction nents of the dental appointment that cause them anxiety.
• Description: Distraction is the technique of diverting the Patients may review information regarding the dental office
patient’s attention from what may be perceived as an un- and environment at home with a preparation book or video
pleasant procedure. Distraction may be achieved by or by viewing the practice website. Parents may model actions
imagination (e.g., stories), clinic design, and audio (e.g., (e.g., opening mouth and touching cheek) and practice

with the child at home using a dental mirror. Successful Parental presence/absence
approximations would continue with an office tour during • Description: The presence or absence of the parent some-
non-clinical hours and another visit in the dental operatory times can be used to gain cooperation for treatment. A wide
to explore the environment. After successful completion of diversity exists in practitioner philosophy and parents’ atti-
each step, an appointment with the dentist and staff may tude regarding parental presence/absence during pediatric
be attempted.91 dental treatment. As establishment of a dental home by 12
• Objectives: The objective of systematic desensitization is for months of age continues to grow in acceptance, parents will
the patient to: expect to be with their infants and young children during
— proceed with dental care after habituation and successful examinations as well as during treatment. Parental involve-
progression of exposure to the environment; ment, especially in their children’s health care, has changed
— identify his fears; dramatically in recent years.29,95 Parents’ desire to be present
— develop relaxation techniques for those fears; and during their child’s treatment does not mean they intellec-
— be gradually exposed, with developed techniques, to tually distrust the dentist; it might mean they are uncom-
situations that evoke his fears and diminish the emotional fortable if they visually cannot verify their child’s safety. It
responses.34 is important to understand the changing emotional needs
• Indications: Use with patients who have experienced fear- of parents because of the growth of a latent but natural sense
invoking stimuli, anxiety, and/or neurodevelopmental to be protective of their children. 96 Practitioners should
disorders (e.g., autism spectrum disorder). become accustomed to this added involvement of parents
• Contraindications: None. and welcome the questions and concerns for their children.
Practitioners must consider parents’ desires and wishes and
Enhancing control be open to a paradigm shift in their own thinking.9,19,29,81,96,97
• Description: Enhancing control is a technique used to allow • Objectives: The objectives of parental presence/absence for
the patient, especially an anxious/fearful one, to assume an parents are to:
active role in the dental experience. The dentist provides the — participate in examinations and treatment;
patient a signal (e.g., raising a hand) to use if he becomes — offer physical and psychological support; and
uncomfortable or needs to briefly interrupt care. The patient — observe the reality of their child’s treatment.
should practice this gesture before treatment is initiated to The objectives of parental presence/absence for practitioners to:
emphasize it is a limited movement away from the operatory — gain the patient’s attention and improve compliance;
field. When the patient employs the signal during dental — avert negative or avoidance behaviors;
procedures, the dentist should quickly respond with a pause — establish appropriate dentist-child roles;
in treatment and acknowledge the patient’s concern. En- — enhance effective communication among the dentist,
hancing control has been shown to be effective in reducing child, and parent;
intraoperative pain.92 — minimize anxiety and achieve a positive dental experience;
• Objectives: The objective is to allow a patient to have some and
measure of control during treatment in order to contain — facilitate rapid informed consent for changes in treatment
emotions and deter disruptive behaviors.92,93 or behavior guidance.
• Indications: Use with patients who can communicate. • Indications: Use with any patient.
• Contraindications: None, but if used prematurely, fear may • Contraindications: Parents who are unwilling or unable to
increase due to an implied concern about the impending extend effective support.
procedure.
Additional considerations for dental patients with anxiety or
Communication techniques for parents (and age-appropriate special health care needs
patients) Sensory-adapted dental environments (SADE)
Because parents are the legal guardians of minors, successful • Description: The SADE intervention includes adaptions of
bi-directional communication between the dentist/staff and the the clinical setting (e.g., dimmed lighting, moving projec-
parent is essential to assure effective guidance of the child’s tions such as fish or bubbles on the ceiling, soothing
behavior.52 Socioeconomic status, stress level, marital discord, background music, application of wrap/blanket around the
dental attitudes aligned with a different cultural heritage, and child to provide deep pressure input) to produce a calming
linguistic skills may present challenges to open and clear effect.91,98
communication. 23,26,94 Communication techniques such as • Objectives: The objective of SADE is to enhance relaxation
ask-tell-ask, teach back, and motivational interviewing can and avert negative or avoidance behaviors.99
reflect the dentist/staff’s caring for and engaging in a patient/ • Indications: Use with patients having autism spectrum
parent centered-approach.26 These techniques are presented in disorder, sensory processing difficulties, other disabilities, or
Appendix 3. dental anxiety.100
• Contraindications: None.

Animal-assisted therapy (AAT) Nitrous oxide/oxygen inhalation

• Description: AAT has been beneficial in a variety of settings • Description: Nitrous oxide/oxygen inhalation is a safe and
including the dental environment.101 It is a goal-oriented effective technique to reduce anxiety and enhance effective
intervention which utilizes a trained animal in a healthcare communication. Its onset of action is rapid, the effects
setting to improve interactions or decrease a patient’s anxiety, easily are titrated and reversible, and recovery is rapid and
pain, or distress. Unlike animal-assisted activities (e.g., a pet complete. Additionally, nitrous oxide/oxygen inhalation
entertains patients in the waiting area), AAT appointments mediates a variable degree of analgesia, amnesia, and gag
are scheduled for specific time and duration to include an reflex reduction. The need to diagnose and treat, as well
animal that has undergone temperament testing, rigorous as the safety of the patient and practitioner, should be
training, and certification. The animal, which is available considered before the use of nitrous oxide/oxygen analgesia/
for companionship during the dental visit, can help break anxiolysis. If nitrous oxide/oxygen inhalation is used in con-
communication barriers and enable the patient to establish a centrations greater than 50 percent or in combination with
safe and comforting relationship, thereby reducing treatment- other sedating medications (e.g., benzodiazepines, opioids),
related stress. For each visit, the goals and results of the the likelihood for moderate or deep sedation increases.108 In
intervention should be documented. these situations, the clinician must be prepared to institute
• Objectives: The objectives of AAT include to: the guidelines for moderate or deep sedation. 5 Detailed
— enhance interactions between the patient and dental team; information concerning the indications, contraindications,
— calm or comfort an anxious or fearful patient; and additional clinical considerations appear in the AAPD’s
— provide a distraction from a potentially stressful situation; Use of Nitrous Oxide for Pediatric Dental Patients 4 and
and Guidelines for Monitoring and Management of Pediatric
— decrease perceived pain.102 Patients Before, During and After Sedation for Diagnostic
The health and safety of the animal and its handler need and Therapeutic Procedures 5 by the AAPD and the American
to be maintained.102 Academy of Pediatrics.
• Indications: Use AAT as an adjunctive technique to decrease • Objectives: The objectives of nitrous oxide/oxygen inhala-
a patient’s anxiety, pain, or emotional distress. tion include to:
• Contraindications: The contraindications for the parent: — reduce or eliminate anxiety;
— allergy or other medical condition (e.g., asthma, — reduce untoward movement and reaction to dental
compromised immune system) aggravated by exposure treatment;
to the animal; and — enhance communication and patient cooperation;
— lack of interest in or fear of the therapy animal. — raise the pain reaction threshold;
The contraindications for the parent: — increase tolerance for longer appointments;
— a situation that presents a significant risk to one’s health — aid in treatment of the mentally/physically disabled or
or safety.103 medically compromised patients;
— reduce gagging; and
Picture exchange communication system (PECS) — potentiate the effect of sedatives.
• Description: PECS is a communication technique developed • Indications: Indications for use of nitrous oxide/oxygen
for individuals with limited to no verbal communication inhalation analgesia/anxiolysis include:
abilities, specifically those with autism). The individual — a fearful, anxious, or obstreperous patient;
shares a picture card with a recognizable symbol to express a — certain patients with SHCN;
request or thought. PECS has a one-to-one correspondence — a patient whose gag reflex interferes with dental care;
with objects, people, and concepts, thereby reducing the — a patient for whom profound local anesthesia cannot
degree of ambiguity in communication.104 The patient is be obtained; and
able to initiate communication, and no special training is — a cooperative child undergoing a lengthy dental pro-
required by the recipient. cedure.
• Objectives: The objective is to allow individuals with limited • Contraindications: Contraindications for use of nitrous
to no verbal communication abilities to express requests or oxide/oxygen inhalation may include:
thoughts using symbolic imagery. A prepared picture board — some chronic obstructive pulmonary diseases;108,109
may be present for the dental appointment so the dentist — current upper respiratory tract infections;109
can communicate the steps required for completion (e.g., — recent middle ear disturbance/surgery;109
pictures of a dental mirror, handpiece). The patient may — severe emotional disturbances or drug-related de-
have symbols (e.g., a stop sign) to show they need a brief pendencies;108,109
interruption in the procedure.105 — first trimester of pregnancy;108,110
• Indications: Use as an adjunctive approach to assist individ- — treatment with bleomycin sulfate; 111
uals with limited to no verbal communication abilities — methylenetetrahydrofolate reductase deficiency;112 and
improve exchange of ideas.91,106 — cobalamin (vitamin B-12) deficiency113.
• Contraindications: None.107

Advanced behavior guidance active restraint. If a patient stabilization device is utilized, it

Most children can be managed effectively using the techniques is considered passive restraint. Active and passive restraint
outlined in basic behavior guidance. Such techniques should can be used in combination.
form the foundation for all behavior guidance provided by Stabilization devices such as a papoose board (passive
the dentist. Children, however, occasionally present with restraint) placed around the chest may restrict respirations.
behavioral considerations that require more advanced tech- They must be used with caution, especially for patients with
niques. These children often cannot cooperate due to lack respiratory compromise (e.g., asthma) and/or for patients
of psychological or emotional maturity and/or mental, phys- who will receive medications (e.g., local anesthetics, sedatives)
ical, or medical disability. The advanced behavior guidance that can depress respirations. Because of the associated risks
techniques commonly used and taught in advanced pediatric and possible consequences of use, the dentist is encouraged
dental training programs include protective stabilization, to evaluate thoroughly their use on each patient and possible
sedation, and general anesthesia.49 The use of general anesthesia alternatives. 56,128 Careful, continuous monitoring of the
or sedation for dental rehabilitation may improve quality of life patient is mandatory during protective stabilization.56,128
in children. It is unclear if these behavior guidance techniques Partial or complete stabilization of the patient sometimes
address factors that contribute to the initial dental fear and is necessary to protect the patient, practitioner, staff, or the
anxiety.114,115 Protective stabilization, active or passive, may not parent from injury while providing dental care. The dentist
always be accepted by parents who may be more accepting of always should use the least restrictive, but safe and effective,
pharmacologic behavior guidance.116 protective stabilization.56,128 The use of a mouth prop in a
Consideration of advanced behavior guidance techniques compliant child is not considered protective stabilization.
requires the practitioner to thoroughly assess the patient’s The need to diagnose, treat, and protect the safety of the
medical, dental, and social histories and temperament. Risks, patient, practitioner, staff, and parent should be considered
benefits, and alternatives should be discussed prior to obtaining prior to the use of protective stabilization. The decision to
an informed consent for the recommended technique.117 Skill- use protective stabilization must take into consideration:
ful diagnosis of behavior and safe and effective implementation — alternative behavior guidance modalities;
of these techniques necessitate knowledge and experience that — dental needs of the patient;
are generally beyond the core knowledge students receive — the effect on the quality of dental care;
during predoctoral dental education. While most predoctoral — the patient’s emotional development; and
programs provide didactic exposure to treatment of very — the patient’s medical and physical considerations.
young children (i.e., aged birth through two years), patients Protective stabilization, with or without a restrictive
with special health care needs, and patients requiring device, led by the dentist and performed by the dental team
advanced behavior guidance techniques, hands-on experience requires informed consent from a parent. Informed consent
is lacking.49 Dentists considering the use of advanced behavior must be obtained and documented in the patient’s record
guidance techniques should seek additional training through prior to use of protective stabilization. Furthermore, when
a residency program, a graduate program, and/or an extensive appropriate, an explanation to the patient regarding the
continuing education course that involves both didactic and need for restraint, with an opportunity for the patient to
experiential mentored training. respond, should occur.52,56,129
• Objectives: The objectives of patient stabilization are to:
Protective stabilization — reduce or eliminate untoward movement;
• Description: The use of any type of protective stabilization — protect patient, staff, dentist, or parent from injury; and
in the treatment of infants, children, adolescents, or patients — facilitate delivery of quality dental treatment.
with special health care needs is a topic that concerns health • Indications: Patient stabilization is indicated for:
care providers and care givers.56,118-127 Protective stabilization — a patient who requires immediate diagnosis and/or
is the restriction of a patient’s freedom of movement, with urgent limited treatment and cannot cooperate due to
or without the patient’s permission, to decrease risk of developmental levels (emotional or cognitive), lack of
injury while allowing safe completion of treatment. “A maturity, or mental or physical conditions;
restraint is any manual method, physical or mechanical — a patient who requires urgent care and uncontrolled
device, material, or equipment that immobilizes or reduces movements risk the safety of the patient, staff, dentist, or
the ability of a patient to move his or her arms, legs, body, parent without the use of protective stabilization;
or head freely; or a drug or medication when it is used as a — a previously cooperative patient who quickly becomes
restriction to manage the patient’s behavior or restrict the uncooperative and cooperation cannot be regained by
patient’s freedom of movement and is not a standard treat- basic behavior guidance techniques in order to protect
ment or dosage for the patient’s condition”.128 Protective the patient’s safety and help complete a procedure and/
stabilization can be performed by the dentist, staff, or or stabilize the patient;
parent with or without the aid of a stabilization device.56 If — an uncooperative patient who requires limited (e.g.,
the restriction involves another person(s), it is considered quadrant) treatment and sedation or general anesthesia

may not be an option because the patient does not meet Sedation
sedation criteria or because of a long operating room wait • Description: Sedation can be used safely and effectively with
time, financial considerations, and/or parental preferences patients who are unable to cooperate due to lack of psy-
after other options have been discussed; chological or emotional maturity and/or mental, physical,
— a sedated patient requires limited stabilization to help or medical conditions. Background information and
reduce untoward movement during treatment; and documentation for the use of sedation is detailed in the
— a patient with SHCN exhibits uncontrolled movements Guideline for Monitoring and Management of Pediatric Patients
that would be harmful or significantly interfere with the During and After Sedation for Diagnostic and Therapeutic
quality of care.3 Procedures by the AAPD and the American Academy of
• Contraindications: Patient stabilization is contraindicated Pediatrics.5
for: The need to diagnose and treat, as well as the safety of
— a cooperative non-sedated patient; the patient, practitioner, and staff, should be considered
— an uncooperative patient when there is not a clear need to for the use of sedation. The decision to use sedation must
provide treatment at that particular visit; take into consideration:
— a patient who cannot be immobilized safely due to asso- — alternative behavioral guidance modalities;
ciated medical, psychological, or physical conditions; — dental needs of the patient;
— a patient with a history of physical or psychological — the effect on the quality of dental care;
trauma, including physical or sexual abuse or other — the patient’s emotional development; and
trauma that would place the individual at greater — the patient’s medical and physical considerations.
psychological risk during restraint; • Objectives: The goals of sedation are to:
— a patient with non-emergent treatment needs in order — guard the patient’s safety and welfare;
to accomplish full mouth or multiple quadrant dental — minimize physical discomfort and pain;
rehabilitation; — manage anxiety, minimize psychological trauma, and
— a practitioner’s convenience; and maximize the potential for amnesia;
— a dental team without the requisite knowledge and skills — manage behavior and/or movement so as to allow the
in patient selection and restraining techniques to prevent safe completion of the procedure; and
or minimize psychological stress and/or decrease risk of — return the patient to a state in which safe discharge
physical injury to the patient, the parent, and the staff. from medical supervision, as determined by recognized
• Precautions: The following precautions are recommended: criteria, is possible.
— the patient’s medical history must be reviewed careful- • Indications: Sedation is indicated for:
ly to ascertain if there are any medical conditions (e.g., — fearful/anxious patients for whom basic behavior
asthma) which may compromise respiratory function; guidance techniques have not been successful;
— tightness and duration of the stabilization must be — patients who cannot cooperate due to a lack of psycho-
monitored and reassessed at regular intervals; logical or emotional maturity and/or mental, physical,
— stabilization around extremities or the chest must not or medical conditions; and
actively restrict circulation or respiration; — patients for whom the use of sedation may protect the
— observation of body language and pain assessment must developing psyche and/or reduce medical risk.
be continuous to allow for procedural modifications at • Contraindications: The use of sedation is contraindicated for:
the first sign of distress; and — the cooperative patient with minimal dental needs; and
— stabilization should be terminated as soon as possible in — predisposing medical and/or physical conditions which
a patient who is experiencing severe stress or hysterics would make sedation inadvisable.
to prevent possible physical or psychological trauma. • Documentation: The patient’s record shall include:5
• Documentation: The patient’s record must include: — informed consent that is obtained from the parent and
— indication for stabilization; documented prior to the use of sedation;
— type of stabilization; — pre- and post-operative instructions and information
— informed consent for protective stabilization; provided to the parent;
— reason for parental exclusion during protective stabiliza- — health evaluation;
tion (when applicable); — a time-based record that includes the name, route, site,
— the duration of application of stabilization; time, dosage, and effect on patient of administered
— behavior evaluation/rating during stabilization; drugs;
— any untoward outcomes, such as skin markings; and — the patient’s level of consciousness, responsiveness,
— management implication for future appointments. heart rate, blood pressure, respiratory rate, and oxygen
saturation prior to treatment, at the time of treatment,
and post-operatively until predetermined discharge
criteria have been attained;

— adverse events (if any) and their treatment; and • Objectives: The goals of general anesthesia are to:
— time and condition of the patient at discharge. — provide safe, efficient, and effective dental care;
— eliminate anxiety;
General anesthesia — eliminate untoward movement and reaction to dental
• Description: General anesthesia is a controlled state of treatment;
unconsciousness accompanied by a loss of protective reflexes, — aid in treatment of the mentally- physically-, or
including the ability to maintain an airway independently medically-compromised patient; and
and respond purposefully to physical stimulation or verbal — minimize the patient’s pain response.
command. Depending on the patient, general anesthesia can • Indications: General anesthesia is indicated for patients:
be administered in a hospital or an ambulatory setting, in- — who cannot cooperate due to a lack of psychological or
cluding the dental office. Practitioners who provide in-office emotional maturity and/or mental, physical, or medical
general anesthesia (dentist and the anesthesia provider) should disability;
be familiar with and follow the recommendations found in — for whom local anesthesia is ineffective because of acute
the AAPD’s Use of anesthesia providers in the administration infection, anatomic variations, or allergy;
of office-based deep sedation/general anesthesia to the pediatric — who are extremely uncooperative, fearful, or anxious;
dental patient.6 — who are precommunicative or non-communicative
Because laws and codes vary from state to state, each prac- child or adolescent;
titioner must be familiar with his state guidelines regarding — requiring significant surgical procedures that can be
office-based general anesthesia. The need to diagnose and combined with dental procedures to reduce the number
treat, as well as the safety of the patient, practitioner, and of anesthetic exposures;
staff should be considered for the use of general anesthesia. — for whom the use of general anesthesia may protect
Anesthetic and sedative drugs are used to help ensure the the developing psyche and/or reduce medical risk; and
safety, health, and comfort of children undergoing proce- — requiring immediate, comprehensive oral/dental care
dures. Increasing evidence from research studies suggests the (e.g., due to dental trauma, severe infection/cellulitis,
benefits of these agents should be considered in the context acute pain).
of their potential to cause harmful effects. 130 Additional • Contraindications: The use of general anesthesia is contra-
research is needed to identify any possible risks to young indicated for:
children. “In the absence of conclusive evidence, it would — a healthy, cooperative patient with minimal dental
be unethical to withhold sedation and anesthesia when needs;
necessary”.131 — a very young patient with minimal dental needs that
The decision to use general anesthesia must take into can be addressed with therapeutic interventions (e.g.,
consideration: ITR, fluoride varnish, SDF) and/or treatment deferral;
— alternative modalities; — patient/practitioner convenience; and
— the age of the patient; — predisposing medical conditions which would make
— risk benefit analysis; general anesthesia inadvisable.
— treatment deferral; • Documentation: Prior to the delivery of general anesthesia,
— dental needs of the patient; appropriate documentation shall address the rationale
— the effect on the quality of dental care; for use of general anesthesia, informed consent, instructions
— the patient’s emotional development; provided to the parent, dietary precautions, and preoperative
— the patient’s medical status; and health evaluation. Because laws and codes vary from state
— barriers to care (e.g., finances). to state, each practitioner must be familiar with her state
guidelines. For information regarding requirements for a
time-based anesthesia record, refer to the AAPD’s Use of
Anesthesia Providers in the Administration of Office-based
Deep Sedation/General Anesthesia to the Pediatric Dental
Patient.6
References appear after Appendices.

Appendices
Appendix 3. SEARCH STRATEGIES Search #3. (adults & dentists) 62 results
PubMed®/MEDLINE—date limit August 2019
(((“personality test” OR “personality tests”[MeSH Terms] OR
Search #1. (ped & dental) 2557 results “personality assessment”[MeSH Terms] OR personality[tiab]
OR “gender shifts”[tiab] OR “gender equality” OR ((“Wom-
((((((“behavior management”[tiab] OR “behavior guidance” en, Working”[mesh] OR “Dentists, Women”[mesh]) AND
[tiab] OR “child behavior”[tiab] OR “dental anxiety”[tiab] OR “Practice Patterns, Dentists’”[MeSH Terms]))) AND
“personality test”[tiab] OR “patient cooperation”[tiab] OR (dentist[TIAB] OR dentist[TIAB] OR “Dentists”[Mesh]))
“dentist-patient relations”[tiab] OR “behavior assessment” AND ((“2009/01/01”[PDAT]: “3000/12/31”[PDAT]) AND
[tiab] OR “temperament assessment”[tiab] OR “personality english[filter] NOT (“animals”[MeSH Terms] NOT
assessment”[tiab] OR “treatment deferral”[tiab] OR “humans”[MeSH Terms]))
“treatment delay”[tiab] OR compliance[tiab] OR
adherence[tiab] OR “protective stabilization”[tiab] OR
immobilization[tiab] OR restraints [tiab] OR Sedation Search #4. (adults & parents) 226 results
[tiab] OR general anesthesia[tiab] OR “Restraint, Physical”
[mesh] OR “Protective Devices”[mesh] OR “Immobilization” (((((dental[tiab] OR “dental health services”[MeSH Terms]
[mesh] OR “Behavior Control”[mesh] OR “child behavior” OR dentistry[TIAB] OR “dentistry”[MeSH Terms] OR
[mesh] OR “dental anxiety”[mesh] OR “personality tests” “dental care”[tiab] OR “dental care”[MeSH Terms] OR
[mesh] OR “patient compliance”[mesh] OR “dentist-patient dentist[tiab] OR “dentists”[MeSH Terms] OR “Dental Care
relations”[mesh] OR “personality assessment”[mesh] OR for Children”[mesh] OR “Pediatric Dentistry”[mesh])))
“patient compliance”[mesh] OR “anesthesia, general”[mesh] AND ((Parents[tiab] OR Fathers[tiab] OR mothers[tiab]
OR “Conscious Sedation”[Mesh]))) AND (((dental[tiab] OR parental[tiab] OR Parent[tiab] OR Father[tiab] OR
OR “dental health services”[MeSH Terms] OR dentistry mother[tiab] or “mothers”[MeSH Terms] OR “fathers”
[TIAB] OR “dentistry”[MeSH Terms] OR “dental care” [MeSH Terms] OR “parents”[MeSH Terms]))) AND
[tiab] OR “dental care”[MeSH Terms] OR dentist[tiab] OR (“behavior management”[tiab] OR “behavior guidance”
“dentists”[MeSH Terms] OR “Dental Care for Children” [tiab] OR “dentist parent relations”[tiab] OR “Informed
[mesh] OR “Pediatric Dentistry”[mesh])))) AND (((“infant” consent”[tiab] OR “family compliance”[tiab] OR “parent
[MeSH Terms] OR “infant”[tiab]) OR (“child”[MeSH compliance”[tiab] OR “family adherence”[tiab] OR “parent
Terms] OR “child”[tiab]) OR (“adolescent”[MeSH Terms] adherence”[tiab] OR “parenting style”[tiab] OR “dentist-
OR “adolescent”[tiab]) OR “pediatrics”[MeSH Terms] OR patient relations”[tiab] OR “dentist-patient relations”
“pediatrics”[tiab] OR “pediatric”[tiab])))) AND ((“2009/ [MeSH Terms] OR “Behavior Control”[mesh] OR “pa-
01/01”[PDAT]: “3000/12/31”[PDAT]) AND english tient compliance”[MeSH Terms] OR “Informed Consent”
[filter] NOT (“animals”[MeSH Terms] NOT “humans” [Mesh])) AND (((“2009/01/01”[PDAT]: “3000/12/31”
[MeSH Terms])) [PDAT]) AND english[filter] NOT (“animals”[MeSH
Terms] NOT “humans”[MeSH Terms])))
Search #2. (ped & medical) 1081 results

((“behavior management”[tiab] OR “behavior guidance”[tiab]
OR “toxic stress”[tiab] OR “protective stabilization”[tiab]
OR restraints[tiab] OR “Restraint, Physical”[majr] OR
“Behavior Control”[majr])) AND ((((“infant”[MeSH Terms]
OR “infant”[tiab]) OR (“child”[MeSH Terms] OR “child”
[tiab]) OR (“adolescent”[MeSH Terms] OR “adolescent”
[tiab]) OR “pediatrics”[MeSH Terms] OR “pediatrics”
[tiab]OR “pediatric”[tiab])) AND (((“2009/01/01”
[PDAT]: “3000/12/31”[PDAT]) AND english[filter] NOT
(“animals”[MeSH Terms] NOT “humans”[MeSH Terms]))))

Appendix 2. FRANKL BEHAVIORAL RATING SCALE
1 __ Definitely negative. Refusal of treatment, forceful crying, fearfulness, or any other overt evidence of extreme
negativism.
2 _ Negative. Reluctance to accept treatment, uncooperative, some evidence of negative attitude but not pro-
nounced (sullen, withdrawn).
3 + Positive. Acceptance of treatmen, cautious behavior at times, willingness to comply with the dentist, at times
with reservation, but patient follows the dentist’s directions cooperatively.
4 ++ Definitely positive. Good rapport with the dentist, interest in the dental procedures, laughter and enjoyment.
Appendix 3. SAMPLE COMMUNICATION TECHNIQUES FOR PATIENTS & PARENTS 1
When clinicians share information, they predominantly TELL information, often in too much detail, and in terms that some-
times alarm patients. Information sharing is most effective when it is sensitive to the emotional impact of the words used.
By using a technique of ask-tell-ask, it is possible to improve the patients’ understanding and promote adherence. According
to the adult learning theory, it is important to stay in dialogue (not monologue), begin with an assessment of the patient’s
or parents’ needs, tell small chunks of information tailored to those needs, and check on the patient’s understanding,
emotional reactions, and concerns. This is summarized by the three step format Ask-Tell-Ask.
ASK to assess patient’s emotional state and their desire for information. TELL small amounts of information in simple
language, and ASK about the patient’s understanding, emotional reactions, and concerns. Many conversations between clinicians
and parents sound like Tell-Tell-Tell a process known as doctor babble, because clinicians seem to talk to themselves, rather
than have a conversation with parents or patients.
The Ask-Tell-Ask format maintains dialogue with patients and their parents. The important areas for sharing include:
ASK to assess patient needs:

1. Make sure the setting is conducive.
2. Assess the patient’s physical and emotional state. If patients are upset or anxious, address their emotions and concerns
before trying to share information. Sharing information when the patient is sleepy, sedated, in pain, or emotionally
distraught is not respectful and the information won’t be remembered.
3. Assess the patient’s informational needs. Find out what information the patient wants, and in what format. Some patients
want detailed information about their conditions, tests, and proposed treatments; recommendations for reading; websites;
self-help groups; and/or referrals to other consultants. Others want an overview and general understanding. Patients may
want other family members to be present for support or to help them remember key points. Reaching agreement with
the patient about what information to review may require negotiation if the clinician understands the issues, priorities,
or goals differently than the patient. Also, some patients may need more time, and so it might be wise to discuss the
key points and plan to address others later or refer them to other staff or health educators. Instead of asking, “Do you
have any questions?´ to which patients often reply, “No,” instead ask, “What questions or concerns do you have?” Be sure
to ask, “Anything else?´
4. Assess the patient’s knowledge and understanding. Find out what previous knowledge or relevant experience patients
have about a symptom or about a test or treatment.
5. Assess the patient’s attitudes and motivation. Patients will not be interested in hearing your health information if they
are not motivated or if they have negative attitudes about the outcomes of their efforts, so ask about this directly. Start
by asking general questions about attitudes and motivation: “ So – tell me how you feel about all of this?´ ³ This is a
complicated regimen. How do you think you will manage?´ If patients are not motivated, ask why and help the patient work
through the issues.

TELL information:
1. Keep each bit of information brief. It is difficult to understand and retain large amounts of information, especially
when one is physically ill, upset, or fearful.
2. Use a systematic approach. For example, name the problem, the next step, what to expect, and what the patient can do.
3. Support the patient’s prior successes. Explicitly mention and appreciate patients’ previous efforts and accomplishments
in coping with previous problems or illness.
4. Personalize the information. Personalize your information by referring to the patient’s personal and family history.
5. Use simple language; avoid jargon. Be mindful of how key points are framed.
6. Choose words that do not unnecessarily alarm. Words and phrases a practitioner takes for granted may be misinter-
preted or alarm patients and families.
7. Use visual aids, and share supplemental resources. Find reliable resources and educational aids to meet the needs
of your patients.
ASK: Continue to assess needs, comprehension, and concerns.

After each bit of telling, stop and check in with patients. When finished with information sharing, make a final check. This
step closes the feedback loop with patients and helps the practitioner understand what patients hear, whether they are
taking home the intended messages, and how they feel about the situation. The second ASK section consists of the
following items:
1. Check for patients’ comprehension. ASK about the patients’ understanding. This ASK improves patient recall, satis-
faction, and adherence.
2. Check for emotional responses and respond appropriately. Letting patients know their concerns and worries have
been heard is compassionate, improves outcomes, and takes little time.
3. Check about barriers. Patients may face external obstacles as well as internal emotional responses that inhibit them
from overcoming obstacles.
Teach Back
A strategy called teach back is similar. The dentist or dental staff asks the patient to teach back what he has learned. This
may be especially effective for patients with low literacy who cannot rely on written reminders. It is important to present
the process as part of the normal routine. This pertains to explanations or demonstrations: “I always check in with
my patients to make sure that I’ve demonstrated things clearly. Can you show me how you’re going to floss your teeth?” If the
patient’s demonstration is incorrect, the dentist may say, “I’m sorry, I guess I didn’t explain things all that well: let me try again.”
Then go over the information again and ask the patient to teach it back to you again.
Motivational Interviewing
Motivational interviewing facilitates behavior change by helping patients or parents explore and resolve their ambivalence
about change. It is done in a collaborative style which supports the autonomy and self-efficacy of the patient and uses the
patient’s own reasons for change. It increases the patient’s confidence and reduces defensiveness. Motivational interviewing
keeps the responsibility to change with the patient and/or parent, which helps to decrease staff burnout. In dentistry, it
is useful in counseling about brushing, flossing, fluoride varnish, reducing sugar sweetened beverages, and smoking cessation.
Open-ended questions, affirmations, reflective listening, and summarizing (OARS) characterize the patient-centered approach.
It is especially helpful in higher levels of resistance, anger, or entrenched patterns. Motivational interviewing is empowering to
both staff and patients and, by design, is not adversarial or shaming.
1 Adapted from Goleman J. Cultural factors affecting behavior guidance and family compliance. Pediatr Dent 2014;36(2):121-7.
Copyright © 2014, American Academy of Pediatric Dentistry, “www.aapd.org”.

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Dent 2019;29(3):301-9.

BEST PRACTICES: PROTECTIVE STABILIZATION
Use of Protective Stabilization for Pediatric Dental

Patients
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Use of pro-
2020 tective stabilization for pediatric dental patients. The Reference Manual
Purpose Definitions
The American Academy of Pediatric Dentistry (AAPD) Physical restraint is broadly defined by the Centers for
believes that all infants, children, adolescents, and individuals Medicare and Medicaid Services as “(A) Any manual method,
with special health care needs (SHCN) are entitled to receive physical or mechanical device, material, or equipment that
oral health care that meets the treatment and ethical principles immobilizes or reduces the ability of a patient to move his or
of our specialty. The AAPD has included use of protective her arms, legs, body, or head freely; or (B) A drug or medication
stabilization (formerly referred to as physical restraint and med- when it is used as a restriction to manage the patient’s behavior
ical immobilization) in its guidelines on behavior guidance or restrict the patient’s freedom of movement and is not a
since 1990.1,2 This separate document, specific to protective standard treatment or dosage for the patient’s condition.”5 This
stabilization, provides additional information to assist the definition has limitations when applied to dentistry as it does
dental professional and other stakeholders in understanding not accurately or comprehensively reflect the indications or
the indications for and developing appropriate prac tices in utilization of restraint in dentistry.
the use of protective stabilization as an advanced behavior Protective stabilization is the term utilized in dentistry for
guidance technique in contemporary pediatric dentistry. This the physical limitation of a patient’s movement by a person or
advanced technique must be integrated into an overall behav- restrictive equipment, materials or devices for a finite period of
ior guidance approach that is individualized for each patient time6 in order to safely provide examination, diagnosis, and/or
in the context of promoting a positive dental attitude for the treatment. The definition of protective stabilization is similar
patient, while ensuring the highest standards of safety and to that used for restraint in other healthcare disciplines. 5,8
quality of care. Other terms such as medical immobilization and medical
immobilization/protective stabilization have been used as de-
Methods scriptors for procedures categorized as protective stabilization.6,9
Recommendations on protective stabilization were developed Active immobilization involves restraint by another person,
by the Council on Clinical Affairs, adopted in 2013 3 and such as the parent, dentist, or dental auxiliary. 9 Passive
revised in 20174. This document is a revision of the previous immobilization utilizes a restraining device.9
version and is based on a review of the current dental and
medical literature related to the use of protective stabilization Background
devices and restraint in the treatment of infants, children, Pediatric dentists receive formal education and training to gain
adolescents, and patients with SHCN in the dental office. This the knowledge and skills required to manage the various phys-
revision included electronic database searches using the terms: ical challenges, cognitive capacities, and age-defining traits of
protective stabilization and dentistry, protective stabilization their patients. A dentist who treats children should be able
and medical procedures, medical immobilization, restraint and to assess each child’s developmental level, dental attitude, and
®
dentistry, restraint and medical procedures, Papoose board temperament and also be able to recognize potential barriers
®
and dentistry, Papoose board and medical procedures, and
patient restraint for treatment. Fifty-five articles matched
to delivery of care (e.g., previous unpleasant and/or painful
medical or dental experiences) to help predict the child’s
these criteria and were evaluated by title and/or abstract. reaction to treatment.2 A continuum of non-pharmacological
When data did not appear sufficient or were inconclusive, and pharmacological behavior guidance techniques, including
recommendations were based upon expert and/or consensus protective stabilization, may be employed in providing oral
opinion by experienced researchers and clinicians.
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. SHCN: Special health
care needs.

health care for infants, children, adolescents, and individuals Protective stabilization is considered an advanced behavior
with SHCN.2 Behavior guidance approaches for each patient guidance technique in dentistry.2 Attempts to restrain or sta-
who is unable to cooperate should be customized to the bilize patients without adequate training can leave not only the
individual needs of the child and the desires of the patient, but also the practitioner and staff, at risk for physical
parent * and may include sedation, general anesthesia, protective harm.21,22 Both didactic and hands-on mentored education
stabilization, or referral to another dentist. 2 The AAPD’s beyond dental school is essential to ensure appropriate, safe,
Behavior Guidance for the Pediaric Dental Patient 2 should be and effective implementation of protective stabilization of a
consulted for additional information regarding the spectrum patient unable to cooperate. Advanced training can be attained
of behavior guidance techniques. through an accredited post-doctoral program (e.g., advanced
When determining whether to recommend use of stabiliza- education in general dentistry, general practice residency, pedi-
tion or immobilization techniques, the dentist should consider atric dentistry residency) or an extensive and focused contin-
the patient’s oral health needs, emotional and cognitive devel- uing education course that includes both didactic and mentored
opment levels, medical and physical conditions, and parental hands-on experiences. Formal training will allow the dentist
preferences.10,11 Alternative approaches (e.g., treatment options and staff members to acquire the necessary knowledge and
or deferral, sedation, general anesthesia) and their potential skills in patient selection and in the successful use of restraining
impact on quality of care and the patient’s well-being should techniques to prevent or minimize psychological stress and/or
be included in the deliberation.10,11 Socioeconomic status, geo- decrease risk of physical injury to the patient, the parent, and
graphic location, and ethnic/cultural differences of patients and the staff. Providing the opportunity for the staff members to
their parents may influence parental preference for behavior debrief following the use of protective stabilization should be
management techniques.12,13 considered.23 Currently, at least one state (Colorado) requires
Indications for protective stabilization along with practitioner training beyond basic dental education in order for the
and parent acceptance have been evaluated in the literature. A practitioner to utilize protective stabilization devices.24
recent survey demonstrated over 50 percent use and acceptance
of protective stabilization devices among practicing board- Consent. Protective stabilization, with or without a restrictive
certified pediatric dentists. 14 Practitioner gender, practice device, led by the dentist and performed by the dental team
setting, region, and perception of parental acceptance were requires informed consent from a parent.25,26 A parent’s sig-
important factors relating to protective stabilization use and nature on a consent form should not preclude a thorough
acceptance.14,15 discussion of the procedure. The practitioner must explain the
benefits and risks of protective stabilization, as well as alter-
Recommendations native treatment options (e.g., interim therapeutic restoration
Education. Didactic and clinical experiences vary for pre- [ITR], silver diamine fluoride [SDF], treatment deferral) and
doctoral students between and within dental schools.16 While alternative behavior guidance techniques (e.g., sedation, gen-
some schools provide didactic and hands-on training in eral anesthesia), and assist the parent in determining the most
advanced behavior guidance, others offer limited exposure. A appropriate approach to treat his/her child.27 Informed consent
survey of pre-doctoral program directors found a majority discussion, when possible, should occur on a day separate from
of dental schools spend fewer than five classroom hours on the treatment.28,29 Supplements such as informational booklets
behavior guidance techniques.9 Furthermore, 42 percent of or videos may be helpful to the parent and/or patient in
institutions reported fewer than 25 percent of students had understanding the proposed procedure. Informed consent
one hands-on experience with passive immobilization for must be obtained and documented in the patient’s record
non-sedated patients, while 27 percent of programs provided prior to performing protective stabilization.6,22,30,31 If a patient’s
no clinical experiences.9 A predoctoral dental survey demon- behavior during treatment necessitates a change in stabilization
strated 73 percent of students were instructed on use of an procedure or technique, further consent must be obtained and
®
immobilization device (Papoose board); however, only 11
percent observed use in clinical settings, with two percent
documented.30
When appropriate, an explanation to the patient regarding
actually using it on a patient.17 Therefore, graduates from dental the need for restraint, with an opportunity for the patient to
school may lack knowledge and competency in the use of pro- respond, should occur.26 Although a minor does not have the
tective stabilization. Limited training in protective stabilization statutory right to give or refuse consent for treatment, the
is not unique to dentistry as other health care disciplines have child’s wishes and feelings (assent) should be considered when
suggested a need for advanced training and guidelines.8,18-20 addressing the issue of consent. 30,32 Also, when providing
* In all AAPD oral health care policies and clinical recommendations the term “parent” has a broad meaning encompassing a natural/biological father or mother
of a child with full parental legal rights, a custodial parent who in the case of divorce has been awarded legal custody of a child, a person appointed by a court
to be the legal guardian of a minor child, or a foster parent (a noncustodial parent caring for a child without parental support or protection who was placed by local
welfare services or a court order). American Academy of Pediatric Dentistry. Overview. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy

dental care for adolescents or adults with mild intellectual dis- immobilization is indicated, the least restrictive alternative or
abilities, patient assent for protective stabilization should be technique should be used.23,38
considered.33 A conditional comprehensive explanation of the An accurate, comprehensive, and up-to-date medical history
technique to be used and the reasons for application should is necessary for effective treatment. This would include
be provided.33 careful review of the patient’s medical history to ascertain if
Laws governing informed consent vary by state. It is in- there are any conditions (e.g., asthma) which may compromise
cumbent on the practitioner to be familiar with applicable respiratory function or neuromuscular or bone/skeletal dis-
statutes. Currently, approximately 50 percent of states have orders which may require additional positioning aids due to
adopted the patient-oriented standard.34 Thus, a practitioner rigid extremities.28
may be held liable if a parent has not received all of the Following explanation of the procedures and consent by
information that is essential to his/her decision to accept or the parent, protective stabilization of the patient should begin
reject proposed treatment.33 in conjunction with distraction techniques39 by placing the
Written consent before treatment of a patient is mandated child, in a manner as comfortable as possible, in a supine
by some states.35 Even if not required by state law, detailed position. If restriction of extremity movement is needed, the
written consent for protective stabilization should be obtained dentist may ask a dental auxiliary or parent to employ hand
separately from consent for other procedures as it increases guarding or hold the patient’s hands. Gradually increasing or
the parent’s/patient’s awareness of the procedure.25,30 decreasing levels of restriction in response to the patient’s
behavior is one method of providing protective stabilization.23
Parental presence. Parental presence in the operatory may Full-body protective stabilization, when indicated, should be
help both the parent and child during a difficult experience.36 accomplished in a sequential manner.40 If the stabilization
Ninety-two percent of mothers in one study believed they device includes a head hold, that is activated last. At no time
should have been with their child when he/she was placed on should the device be active to the point of restricting blood
a rigid stabilization board to increase the child’s security and/ flow or respiration.41
or comfort.36 In addition, 90 percent recognized that immo-
bilization protected the children from harm.36 The dentist Equipment. Numerous devices are available to limit move-
should consider allowing parental presence in the operatory ments by a patient unable to cooperate during dental treatment.
or direct visual observation of the patient during use of The ideal characteristics of a passive restraining device to use
protective stabilization unless the health and safety of the as an adjunct to dental procedures include the following:
patient, parent, or the dental staff would be at risk.28 Further, • easily used;
if parents are denied access, they must be informed of the • appropriately sized for the patient;
reason with documentation of the explanation in the patient’s • soft and contoured to minimize potential injury to the
chart.24 If parents choose not to be present, they should be patient;
encouraged to provide positive nurturing support for the • specifically designed for patient stabilization (i.e., not
child both before and after the procedure. Ultimately, a parent improvised equipment)40; and
has the right to terminate use of restraint at any time if he • able to be disinfected.
or she believes the child may be experiencing physical or
psychological trauma due to immobilization. If termination is Stabilization of a patient’s extremities can be accomplished
requested, the practitioner immediately should complete the
necessary steps to bring the procedure to a safe conclusion
® ®
using devices (e.g., Posey straps , Velcro straps, seat belts)
or an extra assistant. If hand guarding or hand holding does
before ending the appointment. not deter disruptive movement of a patient’s hands, wrist
restraints may be utilized.37,42 If a patient is unable (due to
Techniques. Alternative approaches to restricting patient medical diagnosis) or unwilling (due to maladaptive behaviors)
movement during medically-necessary dental care should be to control bodily movement, a full body wrap may need to
explored before immobilizing a patient. Protective stabiliza- be used. Full-body stabilization devices include, but are not
tion should be used only when less restrictive interventions are
not effective. It should not be used as a means of discipline,
® ®
limited to, Papoose Board and Pedi-Wrap .37,42 Devices with
a flat board design may not adapt to the dental chair. Pillows
convenience, or retaliation. Furthermore, the use of protective or beanbags under the board may be used to promote stabil-
stabilization should not induce pain for the patient. ity.28 Stabilization for the head may be accomplished using
Treatment should first be attempted with communicative forearm-body support, a head positioner, or an extra assistant.42
behavior guidance without protective stabilization unless there Positioning devices or stabilizers such as wheelchair head
is a history of maladaptive or combative behavior that could supports or dental chair cushions are adjunct devices that are
be injurious to the patient and/or staff.37 Active stabilization not necessarily considered protective stabilization devices.28
involves limitation of movement by another person, such as Although a mouth prop may be used as an immobilization
the parent, dentist, or dental auxiliary, whereas passive device, the use of a mouth prop in a compliant child is not
(mechanical) stabilization requires use of restraints.9 When considered protective stabilization.

Monitoring. Ongoing awareness/assessment of the patient’s Indications. Protective stabilization is indicated for:
physical and psychological well-being during the dental proce- • a patient who requires immediate diagnosis and/or
dure must be performed.28 Tightness of the stabilization device urgent limited treatment and cannot cooperate due to
must be monitored continuously throughout the procedure.41 developmental levels (emotional or cognitive), lack of
For a patient who is experiencing severe emotional stress, maturity, or medical/physical conditions;
protective stabilization must be terminated as soon as possible • a patient who requires urgent care and uncontrolled
to prevent possible physical or psychological trauma.28 At the movements risk the safety of the patient, staff, dentist,
completion of dental procedures, removal of restraints may be or parent without the use of protective stabilization.
accomplished sequentially with short pauses between stages • a previously cooperative patient who quickly becomes
to assess the patient’s level of cooperation.37 Struggling during uncooperative and cooperation cannot be regained by
removal of restraints may increase the potential for injury to basic behavior guidance techniques in order to protect
the child as well as others. When immobilization has been the patient’s safety and help complete a procedure and/
introduced intra-operatively (i.e., unplanned intervention), or stabilize the patient;
debriefing is beneficial for parent/patient understanding 22 • an uncooperative patient who requires limited (e.g.,
and to discuss management implications for future quadrant) treatment and sedation or general anesthesia
appointments. may not be an option because the patient does not meet
sedation criteria or because of a long operating room
Patients with SHCN. The provider should consider utilizing wait time, financial considerations, and/or parental
alternative behavioral approaches to reduce movement and preferences after other options have been discussed;
resistance as well as increase cooperation when providing • a sedated patient who requires limited stabilization to
medically-necessary dental care for patients with SHCN prior help reduce untoward movements during treatment; and
to implementing protective stabilization. 28,43 Various • a patient with SHCN who exhibits uncontrolled move-
behavioral modification approaches such as distraction, shaping, ments that would be harmful or significantly interfere
modeling, sensory integration, desensitization, and rein- with the quality of care.
forcement are regarded as alternatives.43-45 Non-pharmacological
behavior guidance approach have been effective in patients Contraindications: Protective stabilization is contraindicated
with autism spectrum disorders.46-49 Children and adolescents for:
with SHCN will, at times, require protective stabilization • a cooperative non-sedated patient;
to facilitate completion of necessary dental treatment. 28 • an uncooperative patient when there is not a clear need to
Aggressive, uncontrolled, and impulsive behaviors along with provide treatment at that particular visit;
involuntary movements may cause harm to both the patient • a patient who cannot be immobilized safely due to asso-
and dental personnel.50 Use of protective stabilization reduces ciated medical, psychological, or physical conditions;
potential risks and provides safer management of patients • a patient with a history of physical or psychological
with SHCN. 50,51 Studies have demonstrated that sensory trauma, including physical or sexual abuse or other
adapted environments and techniques such as deep pressure trauma that would place the individual at greater
®
from an immobilization device (Papoose board) provided
comfort, reduced effects of stressful stimuli, and were observed
psychological risk during restraint;
• a patient with non-emergent treatment needs in order
to be non-harmful to special needs patients receiving medical to accomplish full mouth or multiple quadrant dental
and dental care.50,51 One study reported parents of children rehabilitation;
with SHCN had greater acceptance of protective stabilization • the practitioner’s convenience; and
in comparison to parents of children with no disabilities.52 • a dental team without requisite knowledge and skills in
When considering protective stabilization during dental patient selection and restraining techniques to prevent
treatment for patients with SHCN, the dentist in collabora- or minimize psychological stress and/or decrease risk of
tion with the parent must consider the importance of treatment physical injury to the patient, the parent, and the staff.
and the safety consideration of the restraint.33 The dentist
should be cautious when utilizing protective stabilization for Risks. The provider should consider the patient’s emotional
children and adolescents receiving multiple medications. The and cognitive developmental levels and should be aware
propensity of adverse central nervous system or cardiac of potential physical and psychological effects of protective
events occurring may increase when protective stabilization is stabilization. The majority of restraint-related injuries consist
instituted on patients receiving psychotropic or other of minor bruises and scratches, although other more serious
medications.41 injuries have been reported.41,53 Fewer injuries were incurred
due to passive stabilization compared to active stabilization,
and fewer injuries occurred with the use of planned passive
stabilization compared to its use in emergent situations.53
Patients placed on a rigid stabilization board may overheat

during the dental procedure.28 They must never be unattended 7. Roberts JF, Curzon ME, Koch G, Martens LC. Review:
while placed on the board as they may roll out of the chair.38 A Behaviour management techniques in paediatric dentistry.
rigid stabilization board may not allow for complete extension Eur Arch Paediatr Dent 2010;11(4):166-74.
of the neck and, therefore, may compromise airway patency, 8. Svendsen EJ, Pedersen R, Moen A, Bjork IT. Exploring
especially in young children or sedated patients. 54 Proper perspectives on restraint during medical procedures in
training and use of a neck roll may minimize this risk.28,37 paediatric care: A qualitative interview study with nurses
Significant release of adrenal catecholamines may occur in and physicians. Int J Qual Stud Health Well-being 2017;
patients who experience increased agitation when restrained by 12(1):1-11.
staff members or protective stabilizing equipment.41 Excessive 9. Adair SM, Schafer TE, Rockman RA, Waller JL. Survey
catecholamine release may sensitize the heart and cause rhythm of behavior management teaching in predoctoral pediatric
disturbances.41 dentistry programs. Pediatr Dent 2004;26(2):143-50.
The dental provider should acknowledge and abide by the 10. Department of Health, Department for Education. Reduc-
principle to “do no harm” when considering completion of ing the need for restraint or restrictive intervention for
excessive amounts of treatment while the patient is immo- children and young people with learning disabilities, au-
bilized with protective stabilization.55 The physical and psy- tism spectrum disorders, or mental health disabilities.
chological health of the patient should override other factors 2017; Crown copyright. Published to gov.uk. Available
(e.g., practitioner convenience, financial compensation).55 at: “https://assets.publishing.service.gov.uk/government/
uploads/system/uploads/attachment_data/file/663453/
Documentation. The patient’s record must include: Reducing_the_Need_for_Restraint_and_Restrictive_
• indication for stabilization. Intervention.pdf ”. Accessed November 5, 2020.
• type of stabilization. 11. Kennedy R, Binns Frances. Therapeutic safe holding
• informed consent for protective stabilization. with children and young people in hospital. Nurs Child
• reason for parental exclusion during protective stabili- Young People 2016;28(4)28-32.
zation (when applicable). 12. Wells MHJ, McCarthy BA, Tseng CH, Law CS. Usage
• the duration of application of stabilization. of behavior guidance techniques vary by provider and
• behavior evaluation/rating during stabilization. practice characteristics. Pediatr Dent 2018;40(3):201-8.
• any untoward outcomes, such as skin markings. 13. Chang CT, Badger GR, Acharya B, Gaw AF, Barratt MS,
• management implications for future appointments. Chiqet BT. Influence of ethnicity on parental preference
for pediatric dental behavioral management techniques.
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2020:470-3. havioral support strategies. In: Raposa KA, Pearlman SP,
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2013;33(5):213-7.

BEST PRACTICES: USE OF LOCAL ANESTHESIA
Use of Local Anesthesia for Pediatric Dental

Patients
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Use of
2020 local anesthesia for pediatric dental patients. The Reference Manual
Dentistry; 2020:318-23.
Purpose the patient’s medical history is essential to decrease the risk of

The American Academy of Pediatric Dentistry (AAPD) aggravating a medical condition while rendering dental care.
intends this document to help practitioners make decisions Medical consultation should be obtained as needed.
when using local anesthesia to control pain in infants, chil- Many local anesthetic agents are available to facilitate man-
dren, adolescents, and individuals with special health care agement of pain in the dental patient. There are two general
needs during the delivery of oral health care. types of local anesthetic chemical formulations: (1) esters (e.g.,
procaine, benzocaine, tetracaine); and (2) amides (e.g., lido-
Methods caine, mepivacaine, prilocaine, articaine).10
Recommendations on local anesthesia were developed by the Vasoconstrictors (e.g., epinephrine, levonordefrin, norepine-
Council on Clinical Affairs and adopted in 20051, and last phrine) are added to local anesthetics to constrict blood vessels
revised in 2015.2 This update is based upon a literature search in the area of injection. This lowers the rate of absorption of
®
of the Pubmed /MEDLINE database using the terms: local
anesthesia AND dentistry AND systematic review, topical
the local anesthetic into the blood stream, thereby lowering
the risk of toxicity and prolonging the anesthetic action in the
anesthesia AND dentistry, buffered anesthesia AND dentistry. area.11 Epinephrine is a relative contraindication in patients
Additionally, Handbook of Local Anesthesia, 7th edition3 con- with hyperthyroidism, and dose of local anesthetics with epi-
tributed significantly to this revision. When data did not nephrine should be limited.12 Patients with significant cardio-
appear sufficient or were inconclusive, recommendations were vascular disease, thyroid dysfunction, diabetes, or sulfite
based upon expert and/or consensus opinion by experienced sensitivity and those receiving monoamine oxidase inhibitors,
researchers and clinicians. tricyclic antidepressants, antipsychotic drugs, norepinephrine,
or phenothiazines may require a medical consultation to
Background determine the need for a local anesthetic without vasoconstric-
Local anesthesia is the temporary loss of sensation including tor.13 When halogenated gases are used for general anesthesia,
pain in one part of the body produced by a topically-applied the myocardium is sensitized to epinephrine, and such
or injected agent without depressing the level of conscious- situations dictate caution with use of a local anesthetic.13
ness. Local anesthetics act within the neural fibers to inhibit Amide-type local anesthetics no longer are contraindicated
the rapid ionic influx of sodium necessary for neuron impulse in patients with a family history of malignant hyperthermia,
generation.4,5 This helps to prevent transmission of pain sensa- an abnormal elevation in body temperature during general
tion during procedures, which can serve to build trust and anesthesia with inhalation anesthetics or succinylcholine.13
foster the relationship of the patient and dentist, allay fear and If a local anesthetic is injected into an area of infection, its
anxiety, and promote a positive dental attitude. The technique onset will be delayed or even prevented.7,8 The inflammatory
of local anesthetic administration is an important considera- process in an area of infection lowers the pH of the extra-
tion in pediatric patient behavior guidance.6 Age-appropriate cellular tissue, inhibiting anesthetic action as little of the
nonthreatening terminology, distraction, topical anesthetics, active free base form of the anesthetic is allowed to cross into
proper injection technique, and pharmacologic managment the nerve sheath to prevent conduction of nerve impulses.8
can help the patient have a positive experience during admin- Additionally, endocarditis prophylaxis (antibiotics) is not
istration of local anesthesia.6,7 In pediatric dentistry, the dental recommended for routine local anesthetic injections through
professional should be aware of proper dosage (based on body noninfected tissue in patients considered at risk.14
weight) to minimize the chance of toxicity and the prolonged
duration of anesthesia, which can lead to self-inflicted tongue ABBREVIATIONS
or soft tissue trauma.8 Knowledge of gross and neuroanatomy AAPD: American Academy Pediatric Dentistry. ADA: American Den-
of the head and neck allows for proper placement of the tal Association. CNS: Central nervous system. CVS: Cardiovascular
anesthetic solution and helps minimize complications (e.g., system. FDA: U.S. Food and Drug Administration. kg: killogram.
hematoma, trismus, intravascular injection).8,9 Familiarity with lb: pound. mg: milligram. mL: milliliter. PDL: Periodontal ligament.

Topical anesthetics Selection of syringes and needles

The application of a topical anesthetic may help minimize The American Dental Association (ADA) has long standing
discomfort caused during administration of local anesthesia. standards for aspirating syringes for use in the administration
Single drugs often used as topical anesthetics in dentistry in- of local anesthesia.19-21 Needle selection should allow for pro-
clude 20 percent benzocaine, five percent lidocaine, and four found local anesthesia and adequate aspiration.19,20 Needle
percent tetracaine.15 Topical anesthetics are effective on surface gauges range from size 23 to 30, with the lower numbers
tissues (up to two to three millimeters in depth) to reduce pain having the larger inner diameter. Needles with lower numbers
from needle penetration of the oral mucosa.4,15 These agents provide for less deflection as the needle passes through soft
are available in gel, liquid, ointment, patch, and aerosol forms. tissues and for more reliable aspiration.20 The depth of inser-
The U.S. Food and Drug Administration (FDA) has issued tion varies not only by injection technique but also by the age
warnings about the use of compounded topical anesthetics16 and size of the patient. Dental needles are available in three
and the risk of methemoglobinemia.17 Compounded topical lengths: long (32 mm), short (20 mm), and ultrashort (10 mm).
anesthetics are custom-made medications that may bypass the Most needle fractures occur during the administration of
FDA’s drug approval process.16 These products may contain inferior alveolar nerve block with 30-gauge needles.22 Break-
very high combined levels of both amide and ester agents. age can occur when a needle is inserted to the hub, when the
Exposure to high concentrations of local anesthetics can lead needle is weakened due to bending it before insertion into the
to serious adverse reactions, as indicated in the FDA's warning.16 soft tissues, or by patient movement after the needle is
Acquired methemoglobinemia is a serious but rare condition inserted.21-23
that occurs when the ferrous iron in the hemoglobin molecule
is oxidized to the ferric state. This molecule is known as Injectable local anesthetic agents
methemoglobin, which is incapable of carrying oxygen.18 Risk Local amide anesthetics available for dental usage include
of acquired methemoglobinemia has been associated primarily lidocaine, mepivacaine, articaine, prilocaine, and bupivacaine
with two local anesthetics: prilocaine and benzocaine.13 Benzo- (Table). Absolute contraindications for local anesthetics include
caine is contraindicated in patients with a history of methe- a documented local anesthetic allergy.15 True allergy to an
moglobinemia and should not be used in children younger amide is exceedingly rare.15 Allergy to one amide does not rule
than two years of age.17 out the use of another amide, but allergy to one ester rules
out use of another ester.15 Potassium metabisulfate is used as
a preservative in local anesthetics containing epinephrine. For
patients having an allergy to bisulfates,
Table. INJECTABLE LOCAL ANESTHETICS ( Adapted from Coté CJ et al.32 )
use of a local anesthetic without a
vasoconstrictor is indicated.24 Local
Anesthetic Duration Maximum doseB mg anesthetic/ mg vasoconstrictor/ anesthetics without vasoconstrictors
in minutesA 1.7 mL cartridge 1.7 mL cartridge can undergo rapid systemic absorption
mg/kg mg/lb
which may result in overdose.24
Lidocainec 90-200 4.4 2
While the prolonged effect of a long-
2%+1:50,000 epinephrine 34 0.034 mg
acting local anesthetic (i.e., bupivacaine)
2%+1:100,000 epinephrine 34 0.017 mg can be beneficial for post-operative pain
Articaine 60-230 7 3.2 in adults, the concomitant increased
4%+1:100,000 epinephrine 68 0.017 mg risk of self-inflicted injury infers that it
4%+1:200,000 epinephrine 68 0.0085 mg is contraindicated for the child or the
physically or intellectually disabled
Mepivacaine D 120-240 4.4 2
patient.15 Claims have been made
3% plain 51 —
that articaine can diffuse through hard
2%+1:20,000 levonordefrin 34 0.085 mg
and soft tissue from a buccal infiltration
BupivacaineE 180-600 1.3 0.6 to provide lingual or palatal soft tissue
0.5%+1:200,000 epinephrine 8.5 0.0085 mg anesthesia.15 Systematic reviews compar-
ing articaine versus lidocaine have
A Duration of anesthesia varies greatly depending on concentration, total dose, and site of administration; use
concluded they present the same efficacy
of epinephrine; and the patient’s age.
B Use lowest total dose that provides effective anesthesia. Lower doses should be used in very vascular areas.
with no differences in patient-reported
Doses should be decreased by 30 percent in infants younger than six months. For improved safety, AAPD, pain25 and that articaine is more effective
in conjunction with the American Academy of Pediatrics, recommends a dosing schedule for dental pro- in anesthetic success in mandibular first
cedures that is more conservative that the manufacturer’s recommended dose (MRD). permanent molar areas26 as well as
C The table lists the long-established pediatric dental maximum dose of lidocaine as 4.4 mg/kg; however, the
MRD is 7 mg/kg.
superior for inferior alveolar nerve
D Use in pediatric patients under four years of age is not recommended. block in patient with irreversible
E The prolonged anesthesia of bupivacaine can increase risk of self-inflicted soft tissue injury. pulpitis27.

Prilocaine is contraindicated in patients with methe- followed by depression) in the central nervous system (CNS).33
moglobinemia, sickle cell anemia, anemia, or symptoms of The classic overdose reaction to local anesthetic is generalized
hypoxia or in patients receiving acetaminophen or phenacetin, tonic-clinic convulsion.33 Early subjective indications of toxic-
since both medications elevate methemoglobin levels.15 ity involve the CNS and include dizziness, anxiety, and confu-
The effect of adjusting the pH of local anesthetics in dentistry sion. This may be followed by diplopia, tinnitus, drowsiness, and
has become of interest because the acidic nature of local anes- circumoral numbness or tingling. Objective signs may include
thetics (adjusted to approximately pH of 4.5 to prolong shelf muscle twitching, tremors, talkativeness, slowed speech, and
life) may cause pain during infiltration and delayed onset. One shivering, followed by overt seizure activity. Unconsciousness
systematic review found that local anesthesia buffered with so- and respiratory arrest may occur.10
dium bicarbonate was 2.3 times more likely to achieve success- The cardiovascular system (CVS) response to local anesthetic
ful anesthesia than nonbuffered local anesthesia for participants toxicity also is biphasic. Initially, the CVS is subject to stimu-
with a clinical diagnosis of symptomatic irreversible pulpitis lation; heart rate and blood pressure may increase. As plasma
requiring endodontic treatment.28 Another systematic review levels of the anesthetic increase, however, vasodilatation occurs
found that the pH adjustment was not effective in reducing followed by depression of the myocardium with subsequent fall
pain of intraoral injections in normal or inflamed tissues or in blood pressure. Bradycardia and cardiac arrest may follow.
reducing the time of anesthesia onset, but it had a slight re- The cardiodepressant effects of local anesthetics are not seen
duction on the onset time with inferior alveolar injections until there is a significantly elevated level in the blood.15
for pulpitis.29 This review concluded that the reduced time of Local anesthetic toxicity can be prevented by careful in-
onset may not be clinically relevant considering the time jection technique, watchful observation of the patient, and
required to prepare the buffered agent.29 Similar results were knowledge of the maximum dosage based on body weight. It
found in children ages six to 12-years-old.30 should be recognized that half the volume of a four percent
local anesthetic should be used compared to a two percent
Documentation of local anesthesia solution with the same dosing recommendation. Practitioners
The patient record is an essential component of the delivery should aspirate before agent delivery during every injection and
of competent and quality oral health care.31 Following each inject slowly.15 Aspiration during injections decreases the risk
appointment, an entry is made in the record that accurately of an intravascular injection, and a slow injection technique
and objectively summarizes that visit. Appropriate documen- reduces tissue distortion and related discomfort. After the in-
tation includes specific information relative to the administra- jection, the doctor, hygienist, or assistant should remain with
tion of local anesthesia. This would include, at a minimum, the patient while the anesthetic begins to take effect. Early rec-
the type and dosage of local anesthetic administered.31 ognition of a toxic response is critical for effective management.
Documentation also may include the type of injection(s) When signs or symptoms of toxicity are noted, administration
administered (e.g., infiltration, block, intraosseous), needle of the local anesthetic agent should be discontinued. Additional
selection, and patient’s reaction to the injection. For example, emergency management, including patient rescue and activation
local anesthesia administration might be recorded as: mandibu- of emergency medical services, is based on the severity of the
lar block with 27-short; 34 milligrams (mg) 2% lidocaine with reaction.4
0.017 mg epinephrine [or 1/100,000 epinephrine]; tolerated
procedure well. In patients for whom the maximum dosage of Allergy to local anesthesia
local anesthetic may be a concern (e.g., young patients, those Allergic reactions are not dose related but are due to the pa-
undergoing sedation), the body weight should be documented tient’s heightened capacity to react to even a small dose and
preoperatively. Because there may be enhanced sedative effects can manifest in a variety of ways, some of which include
when local anesthetics are administered in conjunction with urticaria, dermatitis, angioedema, fever, photosensitivity, or
sedative drugs, recording doses of all agents on a time-based anaphylaxis.15,24 Emergency management is dependent on the
record can help ensure patient safety.32 Local anesthesia docu- rate and severity of the reaction.
mentation also should include that post-injection instructions
were reviewed with the patient and parent. Paresthesia
Paresthesia is persistent anesthesia beyond the expected dura-
Local anesthetic complications tion. Trauma to the nerve can result in paresthesia and,
Toxicity (overdose) among other etiologies, can be caused by the needle during
Younger pediatric patients are at greater risk for adverse drug the injection.34 Patients who initially experience an electric shock
events.8 Most adverse drug reactions develop either during the sensation during injection may have persistent anesthesia.34
injection or within five to 10 minutes.18 Local anesthetic sys- Paresthesia has been reported to be more common with four
temic toxicity can result from high blood levels caused by percent solutions such as articaine and prilocaine compared
a single inadvertent intravascular injection or repeated injec- to those of lower concentrations.35
tions.6 Local anesthetic causes a biphasic reaction (excitation

Postoperative soft tissue injury Local anesthesia and pregnancy

Self-induced soft tissue trauma (lip and cheek biting) is an The use of local anesthesia during pregnancy is considered
unfortunate clinical complication of local anesthetic use in safe.42 The FDA has established a drug classification system
the oral cavity. Most lesions of this nature are self-limiting and based on their risks to pregnant women and their fetuses.43 In
heal without complications, although bleeding and infection respect to the five categories (A, B, C, D, and X) established
are possible.34 The use of bilateral mandibular blocks does not by the FDA, lidocaine is considered in Category B, the safest
increase the risk of soft tissue trauma when compared to uni- of the local anesthetics.44 Lidocaine is considered to be safe
lateral mandibular blocks or ipsilateral maxillary infiltration.34 for use during breastfeeding.45
Advising the patient/caregiver of a realistic duration of
numbness and post-operative precautions is necessary to de- Recommendations
crease risk of self-induced soft tissue trauma. Visual examples 1. Selection of local anesthetic agents should be based
may help stress the importance of observation during the on the patient’s medical history and mental/
period of numbness. For all local anesthetics, the duration of developmental status, the anticipated duration of the
soft tissue anesthesia is greater than dentinal or osseous anes- dental procedure, and the planned administration of
thesia. Use of phentolamine mesylate injections in patients other agents (e.g., nitrous oxide, sedative agents, gen-
over age six years or at least 15 kilograms (kg) has been shown eral anesthesia).
to reduce the duration of effects of local anesthetic by about 2. Administration of local anesthetic should be based
47 percent in the maxilla and 67 percent in the mandible.36,37 on the body weight of the patient, not to exceed
However, there is no research demonstrating a relationship AAPD recommendations in mg/kg found in Table.
between reduction in soft tissue trauma and the use of shorter Use lowest total dose that provides effective anesthesia.
acting local anesthetics. 3. A topical anesthetic may be used prior to the injec-
tion of a local anesthetic to reduce discomfort asso-
Alternative techniques for delivery of local anesthesia ciated with needle penetration. Systemic absorption
Most local anesthesia procedures in pediatric dentistry involve of the drugs in topical anesthetics must be consid-
traditional methods of infiltration or nerve block techniques ered when calculating the total amount of anesthetic
with a dental syringe, disposable cartridges, and needles as administered.
described so far. Several alternative techniques, however, are 4. Benzocaine is contraindicated in patients with a
available. These include computer-controlled local anesthetic history of methemoglobinemia and should not be
delivery, periodontal injection techniques, needleless systems, used in children younger than two years of age.
and intraseptal or intrapulpal injection. Such techniques may 5. Documentation of local anesthesia administration
improve comfort of injection by better control of the adminis- would include, at a minimum, the type and dosage
tration rate, pressure, and location of anesthetic solutions and of local anesthetic. If the local anesthetic was admin-
result in more successful and controlled anesthesia.38,39 istered in conjunction with sedative drugs, the doses
The mandibular bone of a child usually is less dense than of all agents must be noted on a time-based record.
that of an adult, permitting more rapid and complete diffusion
of the anesthetic.8 Mandibular buccal infiltration anesthesia is Safety and risks
as effective as inferior nerve block anesthesia for some oper- 1. In the Table, the long-established pediatric dental
ative procedures.8 In patients with bleeding disorders, the maximum dose for lidocaine is 4.4 mg/kilograms;
periodontal ligament (PDL) injection minimizes the potential however, 7 mg/kg maximum dose for lidocaine is the
for postoperative bleeding of soft tissue vessels.13 The use of the manufacturer’s recommended dose.
PDL injection or intraosseous methods is contraindicated in 2. Compounded topical anesthetics may contain very
the presence of inflammation or infection at the injection site.38 high combined levels of both amide and ester agents
which can lead to serious adverse reactions.
Local anesthesia with sedation and general anesthesia 3. Reduce local anesthesia dose when combined with
Local anesthetics and sedative agents both depress the CNS. sedative medications.
Therefore, it is recommended that the dose of local anes- 4. Half the volume should be used for four percent
thesia be adjusted downward when sedating children with anesthetic solutions compared to two percent solu-
opioids.40 tions with the same dosing recommendation.
For patients undergoing general anesthesia, the anesthesia 5. Manufacturers do not recommend articaine use in
care provider needs to be aware of the concomitant use of a pediatric dental patients younger than 4-years-old.
local anesthetic containing epinephrine, as epinephrine can 6. Needles should not be bent or inserted to their hub
produce dysrhythmias when used with halogenated hydrocar- to avoid breakage.
bons (e.g., halothane).4 Local anesthesia has been reported to
reduce pain in the postoperative recovery period after general
anesthesia.41

References 16. U.S. Food and Drug Administration. FDA news. FDA
1. American Academy of Pediatric Dentistry. Appropriate warns five firms to stop compounding topical anesthetic
use of local anesthesia for pediatric dental patients. creams, December 2006. Available at: “https://www.
Pediatr Dent 2005;27(Suppl):101-6. docguide.com/fda-warns-five-firms-stop-compounding-
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2015;37(special issue):199-205. potentially fatal blood disorder prompts FDA action on
3. Malamed SF. Handbook of Local Anesthesia. 7th ed. St. oral over-the-counter benzocaine products used for teeth-
Louis, Mo.: Mosby; 2020. ing and mouth pain and prescription local anesthetics.
4. Ogle OE, Mahjoubi G. Local anesthesia: Agents, techni- May 31, 2018. Available at: “https://www.fda.gov/drugs/
ques, and complications. Dent Clin North Am 2012; drug-safety-and-availability/risk-serious-and-potentially-
56(1):133-48. fatal-blood-disorder-prompts-fda-action-oral-over-counter-
5. Malamed SF. Neurophysiology. In: Handbook of Local benzocaine”. Accessed September 24, 2020.
Anesthesia. 7th ed., St. Louis, Mo.: Mosby; 2020:2-26. 18. Trapp L, Will J. Acquired methemoglobinemia revisited.
6. Jones JE, Dean JA. Local anesthesia and pain control for Dent Clin North Am 2010;549(4):665-75.
the child and adolescent. In: Dean JA, ed. McDonald 19. American Dental Association Council on Dental Materials
and Avery’s Dentistry for the Child and Adolescent. 10th and Devices. New American National Standards Institute/
ed. St Louis, Mo.: Mosby; 2016:274-85. American Dental Association specification no. 34 for
7. Malamed SF. Basic injection technique. In: Handbook of dental aspirating syringes. J Am Dent Assoc 1978;97(2):
Local Anesthesia. 7th ed. St. Louis, Mo.: Mosby; 2020: 236-8.
173-85. 20. American Dental Association Council on Dental Mate-
8. Malamed SF. Anesthetic considerations in dental special- rials, Instruments, and Equipment. Addendum to
ties. In: Handbook of Local Anesthesia. 6th ed. St. Louis, American National Standards Institute/American Dental
Mo.: Mosby; 2020:289-307. Association specification No. 34 for dental aspirating
9. Malamed SF. Anatomic considerations. In: Handbook of syringes. J Am Dent Assoc 1982;104(1):69-70.
Local Anesthesia. 7th ed. St. Louis, Mo.: Mosby; 2020: 21. Malamed SF. The needle. In: Handbook of Local Anes-
186-203. thesia. 7th ed., St. Louis, Mo.: Mosby; 2020:99-100.
10. Moore PA, Hersh EV. Local anesthetics: Pharmacology 22. Progrel MA. Broken local anesthetic needles: A case series
and toxicity. Dent Clin North Am 2010;54(4):587-99. of 16 patients, with recommendations. J Am Dent Assoc
11. Malamed SF. Pharmacology of vasoconstrictors. In: 2009;140(12):1517-22.
Handbook of Local Anesthesia. 7th ed. St. Louis, Mo.: 23. Malamed SF, Reed KL, Poorsattar S. Needle breakage:
Mosby; 2020:41-56. Incidence and prevention. Dent Clin North Am 2010;
12. Budenz AW. Local anesthetics and medically complex 54(4):745-56.
patients. J Cal Dent Assoc 2000;28(8):611-9. Available 24. Malamed SF. Systemic complications. In: Handbook of
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ical%20Endodontics/Anesthesia/Local%20anesthesia 330-60.
%20and%20med%20compromised%20pts%20JCDA% 25. Tong HJ, Alzahrani FS, Sim YF, et al. Anaesthetic efficacy
202000.pdf ”. Accessed July 15, 2020. of articaine versus lidocaine in children’s dentistry: A
13. Malamed SF. Physical and psychological evaluation. In: systematic review and meta-analysis. Int J Paediatr Dent
Handbook of Local Anesthesia. 7th ed. St. Louis, Mo.: 2018;28(4):347-60.
Mosby; 2020:134-72. 26. Katyal V. The efficacy and safety of articaine versus ligno-
14. Wilson W, Taubert KA, Gevitz P, et al. Prevention of in- caine in dental treatment: A meta-analysis. J Dent 2010;
fective endocarditis: Guidelines from the American Heart 38(4):307-17.
Association. Circulation e-published April 19, 2007. 27. de Geus JL, da Costa KN, Wambier LM, et al. Different
Available at: “https://www.ahajournals.org/doi/10.1161/ anesthetics on the efficacy of inferior alveolar nerve block
CIRCULATIONAHA.106.183095?url_ver=Z39.88-2003 in patients with irreversible pulpitis. J Am Dent Assoc
&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200 2020;151(2):87-97.
pubmed”. Accessed September 24, 2020. Correction 28. Kattan S, Lee S-M, Hersh EV, Karabucak B. Do buffered
Circulation 2007;116:e376-e377. local anesthetics provide more successful anesthesia than
15. Malamed SF. Clinical action of specific agents. In: non-buffered solutions in patients with pulpally involved
Handbook of Local Anesthesia. 7th ed. St. Louis, Mo.: teeth requiring dental therapy?: A systematic review. J
Mosby; 2020:57-85. Am Dent Assoc 2019;150(3):165-7.

29. Aulestia-Viera PV, Braga MM, Borsatti MA. The effect of 39. Clark TM, Yagiela JA. Advanced techniques and arma-
adjusting the pH of local anaesthetics in dentistry: A mentarium for dental local anesthesia. Dent Clin North
systematic review and meta-analysis. Int Endod J 2018; Am 2010;54(4):757-68.
51(8):862-76. 40. Becker DE, Reed KL. Essentials of local anesthetic phar-
30. Chopra R, Jindal G, Sachdev V, Sandhu M. Double-blind macology. Anesth Prog 2006;53(3):98-109.
crossover study to compare pain experience during inferior 41. Kaufman E, Epstein JB, Gorsky M, Jackson DL, Kadari A.
alveolar nerve block administration using buffered two Preemptive analgesia and local anesthesia as a supplement
percent lidocaine in children. Pediatr Dent 2016;38(1): to general anesthesia: A review. Anes Progress 2005;52(1):
25-9. 29-38.
31. American Academy of Pediatric Dentistry. Guideline on 42. Oral Health Care During Pregnancy Expert Workgroup.
record-keeping. Pediatr Dent 2017;16(6):389-96. Oral Health Care During Pregnancy: A National Sum-
32. Coté CJ, Wilson S. American Academy of Pediatric Den- mary of a Consensus Statement. Washington, D.C.: Na-
tistry, American Academy of Pediatrics. Guidelines for tional Maternal and Child Oral Health Resource Center;
Monitoring and Management of Pediatric Patients Before, 2012. Available at: “https://www.mchoralhealth.org/
During, and After Sedation for Diagnostic and Therapeutic PDFs/OralHealthPregnancyConsensus.pdf ”. Accessed
Procedures. Pediatr Dent 2019;41(4):E26-E52. September 24, 2020.
33. Malamed SF. Pharmacology of local anesthetics. In: 43. U.S. Food and Drug Administration. Content and format
Handbook of Local Anesthesia. 7th ed. St. Louis, Mo.: of labeling for human prescription drug and biological
Mosby; 2020:41-56. products; Requirements for pregnancy and lactation label-
34. Malamed SF. Local complications. In: Handbook of Local ing; Final Rule FDA-2006-N-0515. Department of Health
Anesthesia. 7th ed. St. Louis, Mo.: Mosby; 2020:308-29. and Human Services. Available at: “https://www.fda.gov/
35. Garisto GA, Gaffen AS, Lawrence HP, et al. Occurrence of media/90279/download”. Accessed September 24, 2020.
paresthesia after dental local anesthetic administration in 44. Lee JM, Shin TJ. Use of local anesthetics for dental treat-
the United States. J Am Dent Assoc 2010;141(7):836-44. ment during pregnancy: Safety for parturient. J Dent
36. Tavares M, Goodson MJ, Studen-Pavlovich D, et al. Re- Anesth Pain Med 2017;17(2):81-90.
versal of soft-tissue local anesthesia with phentolamine 45. Drugs and Lactation Database (LactMed). Lidocaine.
mesylate in pediatric patients. J Am Dent Assoc 2008;139 Bethesda, Md.: National Library of Medicine; 2006. Up-
(8):1095-104. dated January 7, 2019. Available at: “https://www.ncbi.
37. Hersh EV, Moore PA, Papas AS, et al. Reversal of soft- nlm.nih.gov/books/NBK501230/”. Accessed September
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1080-93.
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Mosby; 2020:268-88.

BEST PRACTICES: USE OF NITROUS OXIDE
Use of Nitrous Oxide for Pediatric Dental Patients

Latest Revision How to Cite: American Academy of Pediatric Dentistry. Use of
2018 nitrous oxide for pediatric dental patients. The Reference Manual
Purpose return to preprocedure mobility. In children, analgesia/

The American Academy of Pediatric Dentistry (AAPD) anxiolysis may expedite the delivery of procedures that are
recognizes nitrous oxide/oxygen inhalation as a safe and not particularly uncomfortable, but require that the patient
effective technique to reduce anxiety, produce analgesia, and not move.3 It also may allow the patient to tolerate unpleas-
enhance effective communication between a patient and health ant procedures by reducing or relieving anxiety, discomfort,
care provider. The need to diagnose and treat, as well as the or pain. Furthermore, it increases reaction time and reduces
safety of the patient and practitioner, should be considered pressure-induced pain, but does not affect pulpal sensitivity,
before using nitrous oxide. By producing this guideline, the as shown in a double blind, crossover study.5
AAPD intends to assist the dental profession in developing Nitrous oxide is a colorless and virtually odorless gas with
appropriate practices in the use of nitrous oxide/oxygen a faint, sweet smell. It is an effective analgesic/anxiolytic agent
analgesia/anxiolysis for pediatric patients. causing central nervous system (CNS) depression and euphoria
with little effect on the respiratory system.6,7 Nitrous oxide has
Methods multiple mechanisms of action. The analgesic effect of nitrous
These recommendations were developed by the Council on oxide appears to be initiated by neuronal release of endoge-
Clinical Affairs and adopted in 2005. This document is a nous opioid peptides with subsequent activation of opioid
revision of the previous version, last revised in 2013. The receptors and descending gamma-aminobutyric acid type A
revision is based on a review of the current dental and medical (GABAA) receptors and noradrenergic pathways that modu-
literature related to nitrous oxide use. A search was conducted late nociceptive processing at the spinal level. The anxiolytic
®
using the database of PubMed /MEDLINE with the effect involves activation of the GABAA receptor either directly
parameters: nitrous oxide [Mesh] OR nitrous oxide reductase or indirectly through the benzodiazepine binding site. 8,9
[Supplementary Concept], publication date from January 1, Nitrous oxide has rapid uptake, being absorbed quickly from
2012; humans; child: birth-18 years. Thirty-nine articles met the alveoli and held in a simple solution in the serum. It is
these criteria, and applicable articles were chosen and added relatively insoluble, passing down a gradient into other tissues
to the references from the previous document. Additionally, and cells in the body, such as the CNS. It is excreted quickly
the American Dental Association’s Guideline for the Use of from the lungs. Nitrous oxide causes minor depression in
Sedation and General Anesthesia by Dentists 1 and the American cardiac output while peripheral resistance is slightly increased,
Dental Association’s Oral Health Topics – Nitrous Oxide Dental thereby maintaining the blood pressure.5 This is of particular
Best Practices for Nitrous Oxide-Oxygen Use 2 were reviewed. advantage in treating patients with cerebrovascular system
When data did not appear sufficient or were inconclusive, disorders.
recommendations were based upon expert and/or consensus Nitrous oxide is absorbed rapidly, allowing for both rapid
opinion by experienced researchers and clinicians. onset and recovery (two to three minutes). It causes minimal
impairment of any reflexes, thus protecting the cough reflex.6
Background It exhibits a superior safety profile with no recorded fatalities
Dentists have expertise in providing anxiety and pain control or cases of serious morbidity when used within recommended
for their patients. While anxiety and pain can be modified by concentrations.10-13
psychological techniques, in many instances pharmacological The decision to use nitrous oxide/oxygen analgesia/anxiolysis
approaches are required.1 The outcome of pharmacological ap- must take into consideration alternative behavioral guidance
proaches is variable and depends upon each patient’s response modalities, the patient’s dental needs, the effect on the quality
to various drugs. The clinical effect of nitrous oxide/oxygen of dental care, the patient’s emotional development, and the
inhalation, however, is more predictable among the majority patient’s physical considerations. Nitrous oxide generally is
of the population. When used for analgesia/anxiolysis, nitrous
oxide/oxygen inhalation allows for diminution or elimination
ABBREVIATIONS
of pain and anxiety in a conscious patient, while entailing
AAPD: American Academy Pediatric Dentistry. CNS: Central nervous
minimum risk. 3 The patient responds normally to verbal system. GABAA: Gamma-aminobutyric acid type A. L/min: Liters
commands.4 All vital signs are stable, there is no significant per minute.
risk of losing protective reflexes, and the patient is able to

acceptable to children and can be titrated easily. Most children 2. current medications including dose, time, route, and
are enthusiastic about the administration of nitrous oxide/ site of administration.
oxygen; many children report feeling a tingling or warm 3. diseases, disorders, or physical abnormalities and
sensation.14 Objectively, children may appear with their hands pregnancy status.
open, legs limp, and a trancelike expression.14 For some pa- 4. previous hospitalization to include the date and
tients, however, the feeling of losing control may be troubling, purpose.
and children with claustrophobia may find the nasal hood 5. recent illnesses (e.g., cold or congestion) that may
confining and unpleasant.15 compromise the airway.
Nitrous oxide has been associated with bioenvironmental
concerns because of its contribution to the greenhouse effect.16 Contraindications for use of nitrous oxide/oxygen inhalation
Nitrous oxide is emitted naturally by bacteria in soils and may include:
oceans; it is produced by humans through the burning of 1. some chronic obstructive pulmonary diseases.19
fossil fuels and forests and the agricultural practices of soil 2. current upper respiratory tract infections.20
cultivation and nitrogen fertilization. Altogether, nitrous oxide 3. recent middle ear disturbance/surgery.20
contributes about five percent to the greenhouse effect.17,18 4. severe emotional disturbances or drug-related de-
However, only a small fraction of the total nitrous released into pendencies.20
the atmosphere (0.35 to two percent) is actually the result of 5. first trimester of pregnancy.21
medical applications of nitrous oxide gas.18 6. treatment with bleomycin sulfate.22
7. methylenetetrahydrofolate reductase deficiency.23
The objectives of nitrous oxide/oxygen inhalation include: 8. cobalamin (vitamin B12) deficiency.9
1. reduce or eliminate anxiety.
2. reduce untoward movement and reaction to dental Whenever possible, appropriate medical specialists should
treatment. be consulted before administering analgesic/anxiolytic agents
3. enhance communication and patient cooperation. to patients with significant underlying medical conditions
4. raise the pain reaction threshold. (e.g., severe obstructive pulmonary disease, congestive heart
5. increase tolerance for longer appointments. failure, sickle cell disease24, acute otitis media, recent tympanic
6. aid in treatment of the mentally/physically disabled membrane graft25, acute severe head injury26). In addition,
or medically compromised patient. consultation with the prenatal medical provider should pre-
7. reduce gagging. cede use of nitrous oxide/oxygen analgesia/anxiolysis during
8. potentiate the effect of sedatives. pregnancy.27
Disadvantages of nitrous oxide/oxygen inhalation may include:6 Technique of nitrous oxide/oxygen administration
1. lack of potency. Nitrous oxide/oxygen must be administered only by appro-
2. dependant largely on psychological reassurance. priately licensed individuals, or under the direct supervision
3. interference of the nasal hood with injection to an- thereof, according to state law. The practitioner responsible for
terior maxillary region. the treatment of the patient and/or the administration of
4. patient must be able to breathe through the nose. analgesic/anxiolytic agents must be trained in the use of such
5. nitrous oxide pollution and potential occupational agents and techniques and appropriate emergency response.
exposure health hazards. Selection of an appropriately sized nasal hood should be
made. A flow rate of five to six litres per minute (L/min)
Recommendations generally is acceptable to most patients. The flow rate can
Indications for use of nitrous oxide/oxygen analgesia/anxiolysis be adjusted after observation of the reservoir bag. The bag
include: should pulsate gently with each breath and should not
1. a fearful, anxious, or obstreperous patient. be either over- or underinflated. Introduction of 100 percent
2. certain patients with special health care needs. oxygen for one to two minutes followed by titration of ni-
3. a patient whose gag reflex interferes with dental care. trous oxide in 10 percent intervals is recommended. During
4. a patient for whom profound local anesthesia cannot nitrous oxide/oxygen analgesia/anxiolysis, the concentration
be obtained. of nitrous oxide should not routinely exceed 50 percent.
5. a cooperative child undergoing a lengthy dental procedure. Studies have demonstrated that gas concentrations dispensed
by the flow meter vary significantly from the end-expired
Review of the patient’s medical history should be performed alveolar gas concentrations; it is the latter that is responsible
prior to the decision to use nitrous oxide/oxygen analgesia/ for the clinical effects. 28,29 To achieve sedation, clinicians
anxiolysis. This assessment should include: should keep the patient’s talking and mouth breathing to a
1. allergies and previous allergic or adverse drug re- minimum, and the scavenging vacuum should not be so
actions. strong as to prevent adequate ventilation of the lungs with

nitrous oxide.30 A review of records of patients undergoing be avoided by not allowing the patient to go into an uncons-
nitrous oxide-oxygen inhalation sedation demonstrated that cious state.41 Diffusion hypoxia can occur as a result of rapid
the typical patient requires from 30 to 40 percent nitrous release of nitrous oxide from the blood stream into the alveoli,
oxide to achieve ideal sedation.31 Nitrous oxide concentration thereby diluting the concentration of oxygen. This may lead
may be decreased during easier procedures (e.g., restorations) to headache, disorientation, and nausea and can be avoided
and increased during more stimulating ones (e.g., extraction, by administering 100 percent oxygen once the nitrous oxide
injection of local anesthetic). One study found that there flow is terminated.6 While the standard recommendation is to
was no benefit to continuous administration of nitrous administer 100 percent oxygen at the end of the procedure,
oxide after profound anesthesia had been achieved.32 During several studies have questioned the necessity for this step in
treatment, it is important to continue the visual monitoring nitrous oxide protocols in healthy patients.42-45
of the patient’s respiratory rate and level of consciousness.
The effects of nitrous oxide largely are dependent on psycho- Documentation
logical reassurance.33 Therefore, it is important to continue Informed consent must be obtained from the parent and
traditional behavior guidance techniques during treatment. documented in the patient’s record prior to administration
Once the nitrous oxide flow is terminated, 100 percent oxygen of nitrous oxide/oxygen. The practitioner should provide
should be administered until the patient has returned to instructions to the parent regarding pretreatment dietary pre-
pretreatment status.34 The patient must return to pretreatment cautions, if indicated. In addition, the patient’s record should
responsiveness before discharge. include indication for use of nitrous oxide/oxygen inhalation,
nitrous oxide dosage (i.e., percent nitrous oxide/oxygen and/
Monitoring or flow rate), duration of the procedure, and post treatment
The response of patients to commands during procedures per- oxygenation procedure.
formed with analgesia/anxiolysis serves as a guide to their level
of consciousness. Clinical observation of the patient must be Facilities/personnel/equipment
performed during any dental procedure. During nitrous oxide/ All newly installed facilities for delivering nitrous oxide/
oxygen analgesia/anxiolysis, continual clinical observation of oxygen must be checked for proper gas delivery and fail-safe
the patient’s responsiveness, color, and respiratory rate and function prior to use. Inhalation equipment must have the
rhythm must be performed. Spoken responses provide an capacity for delivering 100 percent, and never less than 30
indication that the patient is breathing.3 If any other pharma- percent, oxygen concentration at a flow rate appropiate to the
cologic agent is used in addition to nitrous oxide/oxygen and child’s size. If nitrous oxide/oxygen delivery equipment capable
a local anesthetic, monitoring guidelines for the appropriate of delivering more than 70 percent nitrous oxide and less
level of sedation must be followed.4 than 30 percent oxygen is used, an inline oxygen analyzer
must be used. Additionally, inhalation equipment must have
Adverse effects of nitrous oxide/oxygen inhalation a fail-safe system that is checked and calibrated regularly
Nitrous oxide/oxygen analgesia/anxiolysis has an excellent according to the practitioner’s state laws and regulations. 46
safety record. When administered by trained personnel on The system components, including the reservoir bag, should
carefully selected patients with appropriate equipment and be inspected routinely for cracks, wear, and tears. If detected,
technique, nitrous oxide is a safe and effective agent for repairs should be made immediately. Pressure connections
providing pharmacological guidance of behavior in children. should be tested for leaks when delivery system is turned
Acute and chronic adverse effects of nitrous oxide on the on and each time a tank is changed. Consult state and
patient are rare.35 The most common adverse effects, occurring federal guidelines regarding storage of compressed gas tanks.
in 0.5-1.2 percent of patients, are nausea and vomiting.36,37 A Additional locks at the tanks or mixer/delivery level are
higher incidence is noted with longer administration of nitrous available from many manufacturers to deter individuals from
oxide/oxygen, fluctuations in nitrous oxide levels, lack of ti- accessing nitrous oxide inappropriately.46 The equipment must
tration, increased concentrations of nitrous oxide, and a heavy have an appropriate scavenging system to minimize room air
meal prior to administration of nitrous oxide.6,29,30 Fasting is contamination and occupational risk.
not required for patients undergoing nitrous oxide analgesia/ The practitioner who utilizes nitrous oxide/oxygen analgesia/
anxiolysis. The practitioner, however, may recommend that anxiolysis for a pediatric dental patient shall possess appropri-
only a light meal be consumed in the two hours prior to the ate training and skills and have available the proper facilities,
administration of nitrous oxide.38 personnel, and equipment to manage any reasonably foresee-
Studies have reported negative outcomes associated with able emergency. The practitioner is responsible for managing
use of nitrous oxide greater than 50 percent and as an anes- the potential complications associated with the intended level
thetic during major surgery.39,40 Although rare, silent regurgi- of sedation and the next deeper level. Therefore, because
tation and subsequent aspiration need to be considered with moderate sedation may occur, practitioners should have the
nitrous oxide/oxygen sedation. The concern lies in whether appropriate training and emergency equipment to manage
pharyngeal-laryngeal reflexes remain intact. This problem can this. 4,34 Training and certification in basic life support are

required for all clinical personnel. These individuals should 4. Coté CJ, Wilson S, American Academy of Pediatric
participate in periodic review of the office’s emergency protocol, Dentistry, American Academy of Pediatrics. Guidelines
the emergency drug cart, and simulated exercises to assure for monitoring and management of pediatric patients
proper emergency management response. before, during, and after sedation for diagnosis and
An emergency cart (kit) must be readily accessible. Emer- therapeutic procedures: Update 2016. Pediatr Dent 2016;
gency equipment must be able to accommodate children of 38(4):E13-E39.
all ages and sizes. It should include equipment to resuscitate 5. Groenbaek A, Svensson P, Vaeth M, Hansen I, Poulsen S.
a nonbreathing, unconscious patient and provide continuous A placebo-controlled, double-blind, crossover trial on
support until trained emergency personnel arrive. A positive- analgesic effect of nitrous oxide-oxygen inhalation. Int J
pressure oxygen delivery system capable of administering Paediatr Dent 2014;24(1):69-75.
greater than 90 percent oxygen at a 10 L/min flow for at least 6. Paterson SA, Tahmassebi JF. Pediatric dentistry in the new
60 minutes (650 L, “E” cylinder) must be available. When a millennium: 3. Use of inhalation sedation in pediatric
self-inflating bag valve mask device is used for delivering posi- dentistry. Dent Update 2003;30(7):350-6, 358.
tive pressure oxygen, a 15 L/min flow is recommended. There 7. Saxen M. Pharmacologic management of patient be-
should be documentation that all emergency equipment and havior. In: Dean JA, ed. McDonald and Avery’s Dentistry
drugs are checked and maintained on a regularly scheduled for the Child and Adolescent. 10th ed. St. Louis, Mo.:
basis.4 Where state law mandates equipment and facilities, Elsevier; 2016:9-18.
such statutes should supersede these recommendations. 8. Emmanouil DE, Quock RM. Advances in understand-
ing the actions of nitrous oxide. Anesth Prog 2007;54
Occupational safety (1):9-18.
In the medical literature, long-term exposure to nitrous oxide 9. Sanders RDB, Weimann J, Maze M. Biologic effects
used as a general anesthetic has been linked to bone marrow of nitrous oxide: A mechanistic and toxicologic review.
suppression and reproductive system disturbances.10,49-51 How- Anesthesiology 2008;109(4):707-22.
ever, it has been shown that appropriate scavenging is effective 10. Foley J. A prospective study of the use of nitrous oxide
in reducing these reproductive system effects.21,52 In an effort inhalation sedation for dental treatment in anxious
to reduce occupational health hazards associated with nitrous children. Eur J Paediatr Dent 2005;6(3):21-7.
oxide, the AAPD recommends exposure to ambient nitrous 11. Holyroyd I. Conscious sedation in pediatric dentistry:
oxide be minimized through the use of effective scavenging A short review of the current UK guidelines and the
systems and periodic evaluation and maintenance of the technique of inhalational sedation with nitrous oxide.
delivery and scavenging systems.53-55 Clinicians should try to Paediatr Anaesth 2008;18(1):13-7.
minimize the patient’s talking and mouth breathing during 12. Lyratzopoulos G, Blain KM. Inhalation sedation with
nitrous oxide administration to prevent expired gas from nitrous oxide as an alternative to dental general anesthesia
contaminating the operatory.30 for children. J Public Health Med 2003;25(4):303-12.
13. Wilson S, Gosnell E. Survey of American Academy of
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WebCite at: “http://www.webcitation.org/71Ttkr5Tm”)

BEST PRACTICES: MONITORING AND MANAGEMENT OF SEDATION
Guidelines for Monitoring and Management of

Pediatric Patients Before, During, and After Sedation
for Diagnostic and Therapeutic Procedures
Developed by
American Academy of Pediatric Dentistry,
How to Cite: Coté CJ, Wilson S. American Academy of Pediatric
Dentistry, American Academy of Pediatrics. Guidelines for monitoring
American Academy of Pediatrics and management of pediatric patients before, during, and after se-
dation for diagnostic and therapeutic procedures. Pediatr Dent 2019;
Latest Revision 41(4):E26-E52.
2019 *
Abstract: The safe sedation of children for procedures requires a systematic approach abstract that includes the following: no administration
of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical
conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance
between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway
examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear
understanding of the medication’s pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in
airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appro-
priate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the
patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the
presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report
was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to
offer pediatric providers updated information and guidance in delivering safe sedation to children. (Pediatr Dent 2019;41(4):E26-E52)
Introduction categories and expected physiologic responses as The Joint

The number of diagnostic and minor surgical procedures Commission, the American Society of Anesthesiologists
performed on pediatric patients outside of the traditional (ASA), and the AAPD.56,57,59-61
operating room setting has increased in the past several decades. This revised statement reflects the current understanding of
As a consequence of this change and the increased awareness appropriate monitoring needs of pediatric patients both during
of the importance of providing analgesia and anxiolysis, the and after sedation for a procedure.3,4,11,18,20,21,23,24,33,39,41,44,47,51,62-73
need for sedation for procedures in physicians’ offices, dental The monitoring and care outlined may be exceeded at any
offices, subspecialty procedure suites, imaging facilities, emer- time on the basis of the judgment of the responsible practi-
gency departments, other inpatient hospital settings, and tioner. Although intended to encourage high-quality patient
ambulatory surgery centers also has increased markedly.1-52 In care, adherence to the recommendations in this document
recognition of this need for both elective and emergency use cannot guarantee a specific patient outcome. However, struc-
of sedation in nontraditional settings, the American Academy tured sedation protocols designed to incorporate these safety
of Pediatrics (AAP) and the American Academy of Pediatric principles have been widely implemented and shown to reduce
Dentistry (AAPD) have published a series of guidelines for the morbidity. 11,23,24,27,30-33,35,39,41,44,47,51,74-84 These practice recom-
monitoring and management of pediatric patients during and mendations are proffered with the awareness that, regardless of
after sedation for a procedure.53-58 The purpose of this updated the intended level of sedation or route of drug administration,
report is to unify the guidelines for sedation used by medical the sedation of a pediatric patient represents a continuum and
and dental practitioners; to add clarifications regarding moni- may result in respiratory depression, laryngospasm, impaired
toring modalities, particularly regarding continuous expired airway patency, apnea, loss of the patient’s protective airway
carbon dioxide measurement; to provide updated information reflexes, and cardiovascular instability.38,43,45,47,48,59,62,63,85-112
from the medical and dental literature; and to suggest
methods for further improvement in safety and outcomes.
This document uses the same language to define sedation ABBREVIATIONS
AAP: American Academy of Pediatrics. AAPD: American Academy of
Pediatric Dentistry. APLS: Advanced Pediatric Life Support. ASA:
Copyright © 2019 by American Academy of Pediatrics and American Academy of American Society of Anesthesiologists. BIS: Bispectral index. CPAP:
Pediatric Dentistry. All rights reserved. This report is being published concurrently Continuous positive airway pressure. ECG: Electrocardiography. EEG:
in Pediatrics 2019;143(6):e20191000. The articles are identical. Either citation can be Electroencephalogram / electroencephalography. EMS: Emergency
used when citing this article. medical services. LMA: Laryngeal mask airway. MRI: Magnetic
resonance imaging. OSA: Obstructive sleep apnea. PALS: Pediatric
* The 2019 revision was limited to Deep sedation/General anesthesia—Personnel. advanced life support.

Procedural sedation of pediatric patients has serious the intended level of sedation is “deep,” practitioners must have
associated risks.2,5,38,43,45,47,48,62,63,71,83,85,88-105,107-138 These adverse the skills to rescue from a state of “general anesthesia.” The ability
responses during and after sedation for a diagnostic or thera- to rescue means that practitioners must be able to recognize
peutic procedure may be minimized, but not completely the various levels of sedation and have the skills and age- and
eliminated, by a careful preprocedure review of the patient’s size-appropriate equipment necessary to provide appropriate
underlying medical conditions and consideration of how the cardiopulmonary support if needed.
sedation process might affect or be affected by these condi- These guidelines are intended for all venues in which
tions: for example, children with developmental disabilities sedation for a procedure might be performed (hospital, surgical
have been shown to have a threefold increased incidence of center, freestanding imaging facility, dental facility, or private
desaturation compared with children without developmental office). Sedation and anesthesia in a nonhospital environment
disabilities.74,78,103 Appropriate drug selection for the intended (e.g., private physician’s or dental office, freestanding imaging
procedure, a clear understanding of the sedating medication’s facility) historically have been associated with an increased inci-
pharmacokinetics and pharmacodynamics and drug interactions, dence of “failure to rescue” from adverse events, because these
as well as the presence of an individual with the skills needed settings may lack immediately available backup. Immediate
to rescue a patient from an adverse response are critical.42,48,62,63, activation of emergency medical services (EMS) may be required
92,97,99,125-127,132,133,139-158
Appropriate physiologic monitoring and in such settings, but the practitioner is responsible for life-
continuous observation by personnel not directly involved with support measures while awaiting EMS arrival.63,214 Rescue tech-
the procedure allow for the accurate and rapid diagnosis of niques require specific training and skills. 63,74,215,216 The
complications and initiation of appropriate rescue interven- maintenance of the skills needed to rescue a child with apnea,
tions.44,63,64,67,68,74,90,96,110,159-174 The work of the Pediatric Sedation laryngospasm, and/or airway obstruction include the ability to
Research Consortium has improved the sedation knowledge open the airway, suction secretions, provide continuous positive
base, demonstrating the marked safety of sedation by highly airway pressure (CPAP), perform successful bag-valve-mask
motivated and skilled practitioners from a variety of specialties ventilation, insert an oral airway, a nasopharyngeal airway, or
practicing the above modalities and skills that focus on a cul- a laryngeal mask airway (LMA), and, rarely, perform tracheal
ture of sedation safety. 45,83,95,128-138 However, these ground- intubation. These skills are likely best maintained with frequent
breaking studies also show a low but persistent rate of potential simulation and team training for the management of rare
sedation-induced life-threatening events, such as apnea, airway events.128,130,217-220 Competency with emergency airway man-
obstruction, laryngospasm, pulmonary aspiration, desaturation, agement procedure algorithms is fundamental for safe sedation
and others, even when the sedation is provided under the practice and successful patient rescue (see Figures 1, 2, and 3).215,
direction of a motivated team of specialists.129 These studies have 216,221-223
helped define the skills needed to rescue children experiencing

adverse sedation events. The sedation of children is different
from the sedation of adults. Sedation in children is often admin-
istered to relieve pain and anxiety as well as to modify behavior
(e.g., immobility) so as to allow the safe completion of a pro-
cedure. A child’s ability to control his or her own behavior to
cooperate for a procedure depends both on his or her chrono-
logic age and cognitive/emotional development. Many brief
procedures, such as suture of a minor laceration, may be accom-
plished with distraction and guided imagery techniques, along
with the use of topical/local anesthetics and minimal sedation,
if needed.175-181 However, longer procedures that require im-
mobility involving children younger than 6 years or those with
developmental delay often require an increased depth of sedation
to gain control of their behavior.86,87,103 Children younger than
6 years (particularly those younger than 6 months) may be at
greatest risk of an adverse event.129 Children in this age group
are particularly vulnerable to the sedating medication’s effects on
respiratory drive, airway patency, and protective airway reflexes.62,63
Other modalities, such as careful preparation, parental presence,
hypnosis, distraction, topical local anesthetics, electronic devices
with age-appropriate games or videos, guided imagery, and the
techniques advised by child life specialists, may reduce the need
for or the needed depth of pharmacologic sedation.29,46,49,182-211
Studies have shown that it is common for children to pass
from the intended level of sedation to a deeper, unintended level
of sedation,85,88,212,213 making the concept of rescue essential to
safe sedation. Practitioners of sedation must have the skills to
rescue the patient from a deeper level than that intended for
the procedure. For example, if the intended level of sedation is
“minimal,” practitioners must be able to rescue from “moderate
sedation”; if the intended level of sedation is “moderate,” practi-
tioners must have the skills to rescue from “deep sedation”; if Figure 1. Suggested management of airway obstruction.

Practitioners should have an in-depth knowledge of the

agents they intend to use and their potential complications. A
number of reviews and handbooks for sedating pediatric pa-
tients are available.30,39,65,75,171,172,201,224-233 There are specific situ-
ations that are beyond the scope of this document. Specifically,
guidelines for the delivery of general anesthesia and monitored
anesthesia care (sedation or analgesia), outside or within the
operating room by anesthesiologists or other practitioners
functioning within a department of anesthesiology, are addressed
by policies developed by the ASA and by individual depart-
ments of anesthesiology.234 In addition, guidelines for the seda-
tion of patients undergoing mechanical ventilation in a critical
care environment or for providing analgesia for patients
postoperatively, patients with chronic painful conditions, and
patients in hospice care are beyond the scope of this document.
Goals of Sedation
The goals of sedation in the pediatric patient for diagnostic and
therapeutic procedures are as follows: (1) to guard the patient’s
safety and welfare; (2) to minimize physical discomfort and
pain; (3) to control anxiety, minimize psychological trauma,
and maximize the potential for amnesia; (4) to modify be-
havior and/or movement so as to allow the safe completion of
the procedure; and (5) to return the patient to a state in which
discharge from medical/dental supervision is safe, as deter-
Figure 2. Suggested management of laryngospasm. mined by recognized criteria (see Supplemental Appendix 1).
These goals can best be achieved by selecting the lowest
dose of drug with the highest therapeutic index for the pro-
cedure. It is beyond the scope of this document to specify which
drugs are appropriate for which procedures; however, the selec-
tion of the fewest number of drugs and matching drug selection
to the type and goals of the procedure are essential for safe
practice. For example, analgesic medications, such as opioids or
ketamine, are indicated for painful procedures. For nonpainful
procedures, such as computed tomography or magnetic reso-
nance imaging (MRI), sedatives/hypnotics are preferred. When
both sedation and analgesia are desirable (e.g., fracture re-
duction), either single agents with analgesic/sedative properties
or combination regimens are commonly used. Anxiolysis and
amnesia are additional goals that should be considered in the
selection of agents for particular patients. However, the potential
for an adverse outcome may be increased when 2 or more
sedating medications are administered. 62,127,136,173,235 Recently,
there has been renewed interest in noninvasive routes of medi-
cation administration, including intranasal and inhaled routes
(e.g., nitrous oxide; see below).236
Knowledge of each drug’s time of onset, peak response, and
duration of action is important (e.g., the peak electroencepha-
logram (EEG) effect of intravenous midazolam occurs at ~4.8
minutes, compared with that of diazepam at ~1.6 minutes237-239).
Titration of drug to effect is an important concept; one must
know whether the previous dose has taken full effect before
administering additional drugs. 237 Drugs that have a long
duration of action (e.g., intramuscular pentobarbital, pheno-
thiazines) have fallen out of favor because of unpredictable
responses and prolonged recovery. The use of these drugs re-
quires a longer period of observation even after the child
achieves currently used recovery and discharge criteria. 62,238-241
This concept is particularly important for infants and toddlers
transported in car safety seats; re-sedation after discharge at-
tributable to residual prolonged drug effects may lead to airway
Figure 3. Suggested management of apnea.
obstruction. 62,63,242 In particular, promethazine (Phenergan;
Wyeth Pharmaceuticals, Philadelphia, Pa.) has a “black box

warning” regarding fatal respiratory depression in children on a scheduled basis (see Supplemental Appendices 3 and 4
younger than 2 years. 243 Although the liquid formulation of for suggested drugs and emergency life support equipment
chloral hydrate is no longer commercially available, some hos- to consider before the need for rescue occurs). Monitoring
pital pharmacies now are compounding their own formulations. devices, such as electrocardiography (ECG) machines, pulse
Low-dose chloral hydrate (10–25 mg/kg), in combination with oximeters with size-appropriate probes, end-tidal carbon
other sedating medications, is used commonly in pediatric dioxide monitors, and defibrillators with sizeappropriate
dental practice. patches/paddles, must have a safety and function check on a
regular basis as required by local or state regulation. The use
General Guidelines of emergency checklists is recommended, and these should
Candidates be immediately available at all sedation locations; they can be
Patients who are in ASA classes I and II are frequently considered obtained from http://www.pedsanesthesia.org/.
appropriate candidates for minimal, moderate, or deep sedation
(see Supplemental Appendix 2). Children in ASA classes III Documentation
and IV, children with special needs, and those with anatomic Documentation prior to sedation shall include, but not be
airway abnormalities or moderate to severe tonsillar hyper- limited to, the following recommendations:
trophy present issues that require additional and individual con- 1. Informed consent: The patient record shall document
sideration, particularly for moderate and deep sedation.68,244-249 that appropriate informed consent was obtained accord-
Practitioners are encouraged to consult with appropriate sub- ing to local, state, and institutional requirements.251,252
specialists and/or an anesthesiologist for patients at increased 2. Instructions and information provided to the responsible
risk ofexperiencing adverse sedation events because of their person: The practitioner shall provide verbal and/or writ-
underlying medical/surgical conditions. ten instructions to the responsible person. Information
shall include objectives of the sedation and anticipated
Responsible person changes in behavior during and after sedation.163,253-255 Spe-
The pediatric patient shall be accompanied to and from the cial instructions shall be given to the adult responsible for
treatment facility by a parent, legal guardian, or other respon- infants and toddlers who will be transported home in a
sible person. It is preferable to have 2 adults accompany car safety seat regarding the need to carefully observe the
children who are still in car safety seats if transportation to child’s head position to avoid airway obstruction. Tran-
and from a treatment facility is provided by 1 of the adults.250 sportation in a car safety seat poses a particular risk for
infants who have received medications known to have a
Facilities long half-life, such as chloral hydrate, intramuscular pento-
The practitioner who uses sedation must have immediately avail- barbital, or phenothiazine because deaths after procedural
able facilities, personnel, and equipment to manage emergency sedation have been reported.62,63,238,242,256,257 Consideration
and rescue situations. The most common serious complications for a longer period of observation shall be given if the
of sedation involve compromise of the airway or depressed re- responsible person’s ability to observe the child is limited
spirations resulting in airway obstruction, hypoventilation, (e.g., only 1 adult who also has to drive). Another indica-
laryngospasm, hypoxemia, and apnea. Hypotension and cardio- tion for prolonged observation would be a child with an
pulmonary arrest may occur, usually from the inadequate anatomic airway problem, an underlying medical condition
recognition and treatment of respiratory compromise.42,48,92,97, such as significant obstructive sleep apnea (OSA), or a
99,125,132,139-155 Other rare complications also may include seizures, former preterm infant younger than 60 weeks’ post-
vomiting, and allergic reactions. Facilities providing pediatric conceptional age. A 24-hour telephone number for the
sedation should monitor for, and be prepared to treat, such practitioner or his or her associates shall be provided to
complications. all patients and their families. Instructions shall include
limitations of activities and appropriate dietary precautions.
Back-up emergency services
A protocol for immediate access to back-up emergency services Dietary precautions
shall be clearly outlined. For nonhospital facilities, a protocol Agents used for sedation have the potential to impair protective
for the immediate activation of the EMS system for life- airway reflexes, particularly during deep sedation. Although
threatening complications must be established and maintained.44 a rare occurrence, pulmonary aspiration may occur if the
It should be understood that the availability of EMS does not child regurgitates and cannot protect his or her airway.95,127,258
replace the practitioner’s responsibility to provide initial rescue Therefore, the practitioner should evaluate preceding food
for life-threatening complications. and fluid intake before administering sedation. It is likely that
the risk of aspiration during procedural sedation differs from
On-site monitoring, rescue drugs, and equipment that during general anesthesia involving tracheal intubation
An emergency cart or kit must be immediately accessible. This or other airway manipulations. 259,260 However, the absolute
cart or kit must contain the necessary ageand size-appropriate risk of aspiration during elective procedural sedation is not
equipment (oral and nasal airways, bag-valve-mask device, yet known; the reported incidence varies from ~1 in 825 to
LMAs or other supraglottic devices, laryngoscope blades, ~1 in 30,037.95,127,129,173,244,261 Therefore, standard practice for
tracheal tubes, face masks, blood pressure cuffs, intravenous fasting before elective sedation generally follows the same
catheters, etc) to resuscitate a nonbreathing and unconscious guidelines as for elective general anesthesia; this requirement is
child. The contents of the kit must allow for the provision of particularly important for solids, because aspiration of clear
continuous life support while the patient is being transported gastric contents causes less pulmonary injury than aspiration
to a medical/dental facility or to another area within the facil- of particulate gastric contents.262,263
ity. All equipment and drugs must be checked and maintained

For emergency procedures in children undergoing general anesthesia (Table 1).271 It is permissible for routine necessary
anesthesia, the reported incidence of pulmonary aspiration of medications (e.g., antiseizure medications) to be taken with a
gastric contents from 1 institution is ~1 in 373 compared with sip of clear liquid or water on the day of the procedure.
~1 in 4544 for elective anesthetics.262 Because there are few
published studies with adequate statistical power to provide For the emergency patient
guidance to the practitioner regarding the safety or risk of pul- The practitioner must always balance the possible risks of se-
monary aspiration of gastric contents during procedural sedating nonfasted patients with the benefits of and necessity for
dation,95,127,129,173,244,259-261,264-268 it is unknown whether the risk completing the procedure. In particular, patients with a history
of aspiration is reduced when airway manipulation is not of recent oral intake or with other known risk factors, such
performed/ anticipated (e.g., moderate sedation). However, if a as trauma, decreased level of consciousness, extreme obesity
deeply sedated child requires intervention for airway obstruc- (BMI ≥95% for age and sex), pregnancy, or bowel motility
tion, apnea, or laryngospasm, there is concern that these rescue dysfunction, require careful evaluation before the administration
maneuvers could increase the risk of pulmonary aspiration of of sedatives. When proper fasting has not been ensured, the
gastric contents. For children requiring urgent/emergent se- increased risks of sedation must be carefully weighed against its
dation who do not meet elective fasting guidelines, the risks benefits, and the lightest effective sedation should be used. In
of sedation and possible aspiration are as-yet unknown and this circumstance, additional techniques for achieving analgesia
must be balanced against the benefits of performing the and patient cooperation, such as distraction, guided imagery,
procedure promptly. For example, a prudent practitioner would video games, topical and local anesthetics, hematoma block or
be unlikely to administer deep sedation to a child with a minor nerve blocks, and other techniques advised by child life spe-
condition who just ate a large meal; conversely, it is not justi- cialists, are particularly helpful and should be considered.29,49,
182-201,274,275
fiable to withhold sedation/analgesia from the child in signi-
ficant pain from a displaced fracture who had a small snack a The use of agents with less risk of depressing protective
few hours earlier. Several emergency department studies have airway reflexes, such as ketamine, or moderate sedation, which
reported a low to zero incidence of pulmonary aspiration would also maintain protective reflexes, may be preferred.276
despite variable fasting periods260,264,268; however, each of these Some emergency patients requiring deep sedation (e.g., a trau-
reports have, for the most part, clearly balanced the urgency ma patient who just ate a full meal or a child with a bowel
of the procedure with the need for and depth of sedation.268,269 obstruction) may need to be intubated to protect their airway
Although emergency medicine studies and practice guidelines before they can be sedated.
generally support a less restrictive approach to fasting for brief
urgent/ emergent procedures, such as care of wounds, joint Use of immobilization devices (Protective stabilization)
dislocation, chest tube placement, etc, in healthy children, Immobilization devices, such as papoose boards, must be ap-
further research in many thousands of patients would be de- plied in such a way as to avoid airway obstruction or chest
sirable to better define the relationships between various fasting restriction.277-281 The child’s head position and respiratory ex-
intervals and sedation complications.262-270 cursions should be checked frequently to ensure airway patency.
If an immobilization device is used, a hand or foot should be
Before elective sedation kept exposed, and the child should never be left unattended.
Children undergoing sedation for elective procedures generally If sedating medications are administered in conjunction with
should follow the same fasting guidelines as those for general an immobilization device, monitoring must be used at a level
consistent with the level of sedation achieved.
Table 1. APPROPRIATE INTAKE OF FOOD AND LIQUIDS BEFORE Documentation at the time of sedation
ELECTIVE SEDATION 1. Health evaluation: Before sedation, a health evaluation
Ingested material Minimum
shall be performed by an appropriately licensed practi-
fasting period (h) tioner and reviewed by the sedation team at the time of
treatment for possible interval changes.282 The purpose of
Clear liquids: water, fruit juices without pulp, carbonated beverages, this evaluation is not only to document baseline status
2
clear tea, black coffee but also to determine whether the patient has specific risk
Human milk 4 factors that may warrant additional consultation before
Infant formula sedation. This evaluation also facilitates the identification
6
of patients who will require more advanced airway or car-
Nonhuman milk: because nonhuman milk is similar to solids in
gastric emptying time, the amount ingested must be considered 6 diovascular management skills or alterations in the doses
when determining an appropriate fasting period or types of medications used for procedural sedation.
Light meal: a light meal typically consists of toast and clear liquids. 6
An important concern for the practitioner is the wide-
Meals that include fried or fatty foods or meat may prolong spread use of medications that may interfere with drug
gastric emptying time. Both the amount and type of foods absorption or metabolism and therefore enhance or shorten
ingested must be considered when determining an appropriate
fasting period.
the effect time of sedating medications. Herbal medicines
(e.g., St. John’s wort, ginkgo, ginger, ginseng, garlic)
may alter drug pharmacokinetics through inhibition of
Source: American Society of Anesthesiologists. Practice guidelines for preoperative fasting
and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application the cytochrome P450 system, resulting in prolonged drug
to healthy patients undergoing elective procedures. An updated report by the American effect and altered (increased or decreased) blood drug con-
Society of Anesthesiologists Committee on Standards and Practice Parameters. Available at: centrations (midazolam, cyclosporine, tacrolimus). 283-292
“https://www.asahq.org/For-Members/Practice-Management/Practice-Parameters.aspx”. For
emergent sedation, the practitioner must balance the depth of sedation versus the risk of Kava may increase the effects of sedatives by potentiating
possible aspiration; see also Mace et al.272 and Green et al.273 g-aminobutyric acid inhibitory neurotransmission and

may increase acetaminophen-induced liver toxicity. 293-295 be used in this population. Such a detailed history will help to
Valerian may itself produce sedation that apparently is determine which patients may benefit from a higher level of
mediated through the modulation of g-aminobutyric acid care by an appropriately skilled health care provider, such as
neurotransmission and receptor function.291,296-299 Drugs an anesthesiologist. The health evaluation should also include:
such as erythromycin, cimetidine, and others may also • vital signs, including heart rate, blood pressure, respira-
inhibit the cytochrome P450 system, resulting in prolonged tory rate, room air oxygen saturation, and temperature
sedation with midazolam as well as other medications (for some children who are very upset or noncooperative,
competing for the same enzyme systems. 300-304 Medica- this may not be possible and a note should be written
tions used to treat HIV infection, some anticonvulsants, to document this circumstance);
immunosuppressive drugs, and some psychotropic medica- • physical examination, including a focused evaluation of
tions (often used to treat children with autism spectrum the airway (tonsillar hypertrophy, abnormal anatomy
disorder) may also produce clinically important drug-drug [e.g., mandibular hypoplasia], high Mallampati score
interactions. 305-314 Therefore, a careful drug history is a [i.e., ability to visualize only the hard palate or tip of
vital part of the safe sedation of children. The practitioner the uvula]) to determine whether there is an increased
should consult various sources (a pharmacist, textbooks, risk of airway obstruction74,341-344;
online services, or handheld databases) for specific in- • physical status evaluation (ASA classification [see
formation on drug interactions.315-319 The US Food and Appendix 2]); and
Drug Administration issued a warning in February 2013 • name, address, and telephone number of the child’s
regarding the use of codeine for postoperative pain man- home or parent’s, or caregiver’s cell phone; additional
agement in children undergoing tonsillectomy, particularly information such as the patient’s personal care provider
those with OSA. The safety issue is that some children or medical home is also encouraged.
have duplicated cytochromes that allow greater than ex-
pected conversion of the prodrug codeine to morphine, For hospitalized patients, the current hospital record may
thus resulting in potential overdose; codeine should be suffice for adequate documentation of presedation health;
avoided for postprocedure analgesia.320-324 however, a note shall be written documenting that the chart
was reviewed, positive findings were noted, and a management
The health evaluation should include the following: plan was formulated. If the clinical or emergency condition of
• age and weight (in kg) and gestational age at birth (pre- the patient precludes acquiring complete information before
term infants may have associated sequelae such as sedation, this health evaluation should be obtained as soon as
apnea of prematurity); and feasible.
• health history, including (1) food and medication aller-
gies and previous allergic or adverse drug reactions; (2) 2. Prescriptions. When prescriptions are used for sedation, a
medication/drug history, including dosage, time, route, copy of the prescription or a note describing the content
and site of administration for prescription, over-the- of the prescription should be in the patient’s chart along
counter, herbal, or illicit drugs; (3) relevant diseases, with a description of the instructions that were given to the
physical abnormalities (including genetic syndromes), responsible person. Prescription medications intended to
neurologic impairments that might increase the potential accomplish procedural sedation must not be administered
for airway obstruction, obesity, a history of snoring or without the safety net of direct supervision by trained
OSA, 325-328 or cervical spine instability in Down syn- medical/dental personnel. The administration of sedating
drome, Marfan syndrome, skeletal dysplasia, and other medications at home poses an unacceptable risk, particu-
conditions; (4) pregnancy status (as many as 1% of larly for infants and preschool-aged children traveling in
menarchal females presenting for general anesthesia at car safety seats because deaths as a result of this practice
children’s hospitals are pregnant)329-331 because of concerns have been reported.63,257
for the potential adverse effects of most sedating and
anesthetic drugs on the fetus 329,332-338; (5) history of Documentation during treatment
prematurity (may be associated with subglottic stenosis The patient’s chart shall contain a time-based record that includes
or propensity to apnea after sedation); (6) history of any the name, route, site, time, dosage/kilogram, and patient effect
seizure disorder; (7) summary of previous relevant hospi- of administered drugs. Before sedation, a “time out” should
talizations; (8) history of sedation or general anesthesia be performed to confirm the patient’s name, procedure to be
and any complications or unexpected responses; and (9) performed, and laterality and site of the procedure.59 During
relevant family history, particularly related to anesthesia administration, the inspired concentrations of oxygen and in-
(e.g., muscular dystrophy, malignant hyperthermia, halation sedation agents and the duration of their administra-
pseudocholinesterase deficiency). tion shall be documented. Before drug administration, special
attention must be paid to the calculation of dosage (i.e., mg/kg);
The review of systems should focus on abnormalities of for obese patients, most drug doses should likely be adjusted
cardiac, pulmonary, renal, or hepatic function that might alter lower to ideal body weight rather than actual weight.345 When
the child’s expected responses to sedating/ analgesic medica- a programmable pump is used for the infusion of sedating
tions. A specific query regarding signs and symptoms of medications, the dose/kilogram per minute or hour and the
sleep-disordered breathing and OSA may be helpful. Children child’s weight in kilograms should be double-checked and
with severe OSA who have experienced repeated episodes of confirmed by a separate individual. The patient’s chart shall
desaturation will likely have altered mu receptors and be contain documentation at the time of treatment that the
analgesic at opioid levels one-third to one-half those of a child patient’s level of consciousness and responsiveness, heart rate,
without OSA325-328,339,340; lower titrated doses of opioids should blood pressure, respiratory rate, expired carbon dioxide values,

and oxygen saturation were monitored. Standard vital signs M = Monitors: functioning pulse oximeter with size-appropriate
should be further documented at appropriate intervals during oximeter probes,361,362 end-tidal carbon dioxide monitor,
recovery until the patient attains predetermined discharge criteria and other monitors as appropriate for the procedure
(see Appendix 1). A variety of sedation scoring systems are (e.g., noninvasive blood pressure, ECG, stethoscope)
available that may aid this process.212,238,346-348 Adverse events E = special Equipment or drugs for a particular case (e.g.,
and their treatment shall be documented. defibrillator)
Documentation after treatment Specific guidelines for intended level of sedation

A dedicated and properly equipped recovery area is recom- Minimal sedation
mended (see Appendices 3 and 4). The time and condition of Minimal sedation (old terminology, “anxiolysis”) is a drug-
the child at discharge from thetreatment area or facility shall induced state during which patients respond normally to verbal
be documented, which should include documentation that the commands. Although cognitive function and coordination
child’s level of consciousness and oxygen saturation in room may be impaired, ventilatory and cardiovascular functions are
air have returned to a state that is safe for discharge by recog- unaffected. Children who have received minimal sedation
nized criteria (see Appendix 1). Patients receiving supplemental generally will not require more than observation and intermittent
oxygen before the procedure should have a similar oxygen assessment of their level of sedation. Some children will become
need after the procedure. Because some sedation medications moderately sedated despite the intended level of minimal
are known to have a long half-life and may delay a patient’s sedation; should this occur, then the guidelines for moderate
complete return to baseline or pose the risk of reseda- sedation apply.85,363
tion62,104,256,349,350 and because some patients will have complex
multiorgan medical conditions, a longer period of observation Moderate sedation
in a less intense observation area (e.g., a step-down observation Moderate sedation (old terminology, “conscious sedation” or
area) before discharge from medical/dental supervision may “sedation/ analgesia”) is a drug-induced depression of conscious-
be indicated.239 Several scales to evaluate recovery have been ness during which patients respond purposefully to verbal
devised and validated. 212,346-348,351,352 A simple evaluation tool commands or after light tactile stimulation. No interventions
may be the ability of the infant or child to remain awake for at are required to maintain a patent airway, and spontaneous
least 20 minutes when placed in a quiet environment.238 ventilation is adequate. Cardiovascular function is usually
maintained. The caveat that loss of consciousness should be
Continuous quality improvement unlikely is a particularly important aspect of the definition of
The essence of medical error reduction is a careful examination moderate sedation; drugs and techniques used should carry a
of index events and root-cause analysis of how the event could margin of safety wide enough to render unintended loss of cons-
be avoided in the future.353-359 Therefore, each facility should ciousness unlikely. Because the patient who receives moderate
maintain records that track all adverse events and significant sedation may progress into a state of deep sedation and obtun-
interventions, such as desaturation; apnea; laryngospasm; need dation, the practitioner should be prepared to increase the level
for airway interventions, including the need for placement of of vigilance corresponding to what is necessary for deep sedation.85
supraglottic devices such as an oral airway, nasal trumpet, or
LMA; positive-pressure ventilation; prolonged sedation; un- Personnel
anticipated use of reversal agents; unplanned or prolonged The practitioner. The practitioner responsible for the treatment
hospital admission; sedation failures; inability to complete the of the patient and/or the administration of drugs for sedation
procedure; and unsatisfactory sedation, analgesia, or anxiolysis.360 must be competent to use such techniques, to provide the level
Such events can then be examined for the assessment of risk of monitoring described in these guidelines, and to manage
reduction and improvement in patient/family satisfaction. complications of these techniques (i.e., to be able to rescue
the patient). Because the level of intended sedation may be ex-
Preparation for sedation procedures ceeded, the practitioner must be sufficiently skilled to rescue
Part of the safety net of sedation is using a systematic approach a child with apnea, laryngospasm, and/or airway obstruction,
so as to not overlook having an important drug, piece of including the ability to open the airway, suction secretions,
equipment, or monitor immediately available at the time of provide CPAP, and perform successful bag-valve-mask venti-
a developing emergency. To avoid this problem, it is helpful lation should the child progress to a level of deep sedation.
to use an acronym that allows the same setup and checklist Training in, and maintenance of, advanced pediatric airway
for every procedure. A commonly used acronym useful in skills is required (e.g., pediatric advanced life support [PALS]);
planning and preparation for a procedure is SOAPME, which regular skills reinforcement with simulation is strongly en-
represents the following: couraged.79,80,128,130,217-220,364
S = Size-appropriate suction catheters and a functioning suc- Support personnel. The use of moderate sedation shall include
tion apparatus (e.g., Yankauer-type suction) the provision of a person, in addition to the practitioner,
O = an adequate Oxygen supply and functioning flow meters whose responsibility is to monitor appropriate physiologic
or other devices to allow its delivery parameters and to assist in any supportive or resuscitation mea-
A = size-appropriate Airway equipment (e.g., bag-valve-mask sures, if required. This individual may also be responsible for
or equivalent device [functioning]), nasopharyngeal and assisting with interruptible patient-related tasks of short
oropharyngeal airways, LMA, laryngoscope blades (checked duration, such as holding an instrument or troubleshooting
and functioning), endotracheal tubes, stylets, face mask equipment.60 This individual should be trained in and capable
P = Pharmacy: all the basic drugs needed to support life of providing advanced airway skills (e.g., PALS). The support
during an emergency, including antagonists as indicated person shall have specific assignments in the event of an

emergency and current knowledge of the emergency cart Because sedation medications with a long half-life may delay
inventory. The practitioner and all ancillary personnel should the patient’s complete return to baseline or pose the risk of
participate in periodic reviews, simulation of rare emergencies, resedation, some patients might benefit from a longer period
and practice drills of the facility’s emergency protocol to ensure of less intense observation (e.g., a step-down observation area
proper function of the equipment and coordination of staff roles where multiple patients can be observed simultaneously) before
in such emergencies.133,365-367 It is recommended that at least discharge from medical/dental supervision (see section entitled
1 practitioner be skilled in obtaining vascular access in children. “Documentation Before Sedation” above). 62,256,349,350 A simple
evaluation tool may be the ability of the infant or child to
Monitoring and documentation remain awake for at least 20 minutes when placed in a quiet
Baseline. Before the administration of sedative medications, a environment. 238 Patients who have received reversal agents,
baseline determination of vital signs shall be documented. For such as flumazenil or naloxone, will require a longer period of
some children who are very upset or uncooperative, this may observation, because the duration of the drugs administered may
not be possible, and a note should be written to document this exceed the duration of the antagonist, resulting in re-sedation.
circumstance.
Deep sedation/General anesthesia
During the procedure. The physician/dentist or his or her “Deep sedation” (“deep sedation/ analgesia”) is a drug-induced
designee shall document the name, route, site, time of admin- depression of consciousness during which patients cannot be
istration, and dosage of all drugs administered. If sedation is easily aroused but respond purposefully after repeated verbal
being directed by a physician who is not personally administering or painful stimulation (e.g., purposefully pushing away the
the medications, then recommended practice is for the qualified noxious stimuli). Reflex withdrawal from a painful stimulus is
health care provider administering the medication to confirm the not considered a purposeful response and is more consistent
dose verbally before administration. There shall be continuous with a state of general anesthesia. The ability to independently
monitoring of oxygensaturation and heart rate; when bidirec- maintain ventilatory function may be impaired. Patients may
tional verbal communication between the provider and patient require assistance in maintaining a patent airway, and sponta-
is appropriate and possible (i.e., patient is developmentally able neous ventilation may be inadequate. Cardiovascular function is
and purposefully communicates), monitoring of ventilation by usually maintained. A state of deep sedation may be accompa-
(1) capnography (preferred) or (2) amplified, audible pretracheal nied by partial or complete loss of protective airway reflexes.
stethoscope (e.g., Bluetooth technology) 368-371 or precordial Patients may pass from a state of deep sedation to the state of
stethoscope is strongly recommended. If bidirectional verbal general anesthesia. In some situations, such as during MRI, one
communication is not appropriate or not possible, monitoring is not usually able to assess responses to stimulation, because
of ventilation by capnography (preferred), amplified, audible this would defeat the purpose of sedation, and one should
pretracheal stethoscope, or precordial stethoscope is required. assume that such patients are deeply sedated.
Heart rate, respiratory rate, blood pressure, oxygen saturation, and “General anesthesia” is a drug-induced loss of conscious-
expired carbon dioxide values should be recorded, at minimum, ness during which patients are not arousable, even by painful
every 10 minutes in a time-based record. Note that the exact stimulation. The ability to independently maintain ventilatory
value of expired carbon dioxide is less important than simple function is often impaired. Patients often require assistance in
assessment of continuous respiratory gas exchange. In some maintaining a patent airway, and positive-pressure ventilation
situations in which there is excessive patient agitation or lack of may be required because of depressed spontaneous ventilation
cooperation or during certain procedures such as bronchoscopy, or drug-induced depression of neuromuscular function. Car-
dentistry, or repair of facial lacerations capnography may not be diovascular function may be impaired.
feasible, and this situation should be documented. For unco-
operative children, it is often helpful to defer the initiation of Personnel
capnography until the child becomes sedated. Similarly, the During deep sedation and/or general anesthesia of a pediatric
stimulation of blood pressure cuff inflation may cause arousal patient in a dental facility, there must be at least 2 individu-
or agitation; in such cases, blood pressure monitoring may be als present with the patient throughout the procedure. These
counterproductive and may be documented at less frequent 2 individuals must have appropriate training and up-to-date
intervals (e.g., 10–15 minutes, assuming the patient remains certification in patient rescue, as delineated below, including
stable, well oxygenated, and well perfused). Immobilization de- drug administration and PALS or Advanced Pediatric Life
vices (protective stabilization) should be checked to prevent Support (APLS). One of these 2 must be an independent
airway obstruction or chest restriction. If a restraint device is observer who is independent of performing or assisting with
used, a hand or foot should be kept exposed. The child’s head po- the dental procedure. This individual’s sole responsibility is to
sition should be continuously assessed to ensure airway patency. administer drugs and constantly observe the patient’s vital signs,
depth of sedation, airway patency, and adequacy of ventilation.
After the procedure. The child who has received moderate se- The independent observer must, at a minimum, be trained in
dation must be observed in a suitably equipped recovery area, PALS (or APLS) and capable of managing any airway, venti-
which must have a functioning suction apparatus as well as the latory, or cardiovascular emergency event resulting from the
capacity to deliver 90% oxygen and positive-pressure ventilation deep sedation and/or general anesthesia. The independent
(bag-valve mask) with an adequate oxygen capacity as well as observer must be trained and skilled to establish intravenous
age- and size-appropriate rescue equipment and devices. The access and draw up and administer rescue medications. The
patient’s vital signs should be recorded at specific intervals (e.g., independent observer must have the training and skills to
every 10–15 minutes). If the patient is not fully alert, oxygen rescue a nonbreathing child; a child with airway obstruction; or
saturation and heart rate monitoring shall be used continuously a child with hypotension, anaphylaxis, or cardiorespiratory arrest,
until appropriate discharge criteria are met (see Appendix 1). including the ability to open the airway, suction secretions,

provide CPAP, insert supraglottic devices (oral airway, nasal During deep sedation and/or general anesthesia of a
trumpet, or laryngeal mask airway), and perform successful pediatric patient in a hospital or surgicenter setting, at least 2
bag-valve-mask ventilation, tracheal intubation, and cardiopul- individuals must be present with the patient throughout the
monary resuscitation. The independent observer in the dental procedure with skills in patient rescue and up-to-date PALS
facility, as permitted by state regulation, must be 1 of the (or APLS) certification, as delineated above. One of these indi-
following: a physician anesthesiologist, a certified registered viduals may either administer drugs or direct their adminis-
nurse anesthetist, a second oral surgeon, or a dentist anesthe- tration by the skilled independent observer. The skills of the
siologist. The second individual, who is the practitioner in the individual directing or administering sedation and/or anesthesia
dental facility performing the procedure, must be trained in medications must include those described in the previous
PALS (or APLS) and capable of providing skilled assistance paragraph. Providers who may fulfill the role of the skilled
to the independent observer with the rescue of a child experi- independent observer in a hospital or surgicenter, as permitted
encing any of the adverse events described above. by state regulation, must be a physician with sedation training
and advanced airway skills, such as, but not limited to, a
physician anesthesiologist, an oral surgeon, a dentist
anesthesiologist, or other medical specialists with
Table 2. COMPARISON OF MODERATE AND DEEP SEDATION EQUIPMENT the requisite licensure, training, and competencies;
AND PERSONNEL REQUIREMENTS a certified registered nurse anesthetist or certified
Moderate sedation Deep sedation anesthesiology assistant; or a nurse with advanced
emergency management skills, such as several
Personnel An observer who will monitor the An independent observer whose years of experience in the emergency department,
patient but who may also assist only responsibility is to continu-
with interruptible tasks; should be ously monitor the patient; trained
pediatric recovery room, or intensive care setting
trained in PALS in PALS (i.e., nurses who are experienced with assisting the
individual administering or directing sedation with
Responsible practitioner Skilled to rescue a child with apnea, Skilled to rescue a child with apnea, patient rescue during life-threatening emergencies).
laryngospasm, and/or airway ob- laryngospasm, and/or airway ob-
struction including the ability to struction, including the ability to
open the airway, suction secretions, open the airway, suction secretions, Equipment
provide CPAP, and perform suc- provide CPAP, perform successful In addition to the equipment needed for moderate
cessful bag-valve-mask ventilation; bag-valve-mask ventilation, tra-
recommended that at least 1 prac- cheal intubation, and cardiopulmo- sedation, an ECG monitor and a defibrillator for
titioner should be skilled in ob- nary resuscitation; training in PALS use in pediatric patients should be readily available.
taining vascular access in children; is required; at least 1 practitioner
trained in PALS skilled in obtaining vascular access
in children immediately available Vascular access
Patients receiving deep sedation should have an
Monitoring Pulse oximetry Pulse oximetry intravenous line placed at the start of the proce-
ECG recommended ECG required dure or have a person skilled in establishing vascular
Heart rate Heart rate
Blood pressure Blood pressure
access in pediatric patients immediately available.
Respiration Respiration
Capnography recommended Capnography required Monitoring
A competent individual shall observe the patient
Other equipment Suction equipment, adequate oxy- Suction equipment, adequate oxygen continuously. Monitoring shall include all param-
gen source/supply source/supply, defibrillator required
eters described for moderate sedation. Vital signs,
Documentation Name, route, site, time of adminis- Name, route, site, time of adminis- including heart rate, respiratory rate, blood pressure,
tration, and dosage of all drugs ad- tration, and dosage of all drugs oxygen saturation, and expired carbon dioxide,
ministered administered; continuous oxygen
saturation, heart rate, and ventila-
must be documented at least every 5 minutes in a
Continuous oxygen saturation, heart
rate, and ventilation (capnography tion (capnography required); para- time-based record. Capnography should be used
recommended); parameter s meters recorded at least every 5 for almost all deeply sedated children because of
recorded every 10 minutes minutes
the increased risk of airway/ventilation compro-
Emergency checklists Recommended Recommended mise. Capnography may not be feasible if the
patient is agitated or uncooperative during the initial
Rescue car t properly Required Required phases of sedation or during certain procedures,
s t o c ke d w i t h r e s c u e
drugs and age- and size-
such as bronchoscopy or repair of facial lacerations,
appropriate equipment and this circumstance should be documented. For
(see Appendices 3 and 4) uncooperative children, the capnography monitor
Dedicated recovery area Recommended; initial recording Recommended; initial recording
may be placed once the child becomes sedated.
with rescue cart properly of vital signs may be needed at of vital signs may be needed for at Note that if supplemental oxygen is administered,
s t o c ke d w i t h r e s c u e least every 10 minutes until the least 5-minute intervals until the the capnograph may underestimate the true expired
drugs and age- and size- child begins to awaken, then re- child begins to awaken, then re-
appropriate equipment cording intervals may be increased cording intervals may be increased
carbon dioxide value; of more importance than
(see Appendices 3 and 4) to 10–15 minutes the numeric reading of exhaled carbon dioxide
and dedicated recovery is the assurance of continuous respiratory gas ex-
p e r s o n n e l; a d e q u a te change (i.e., continuous waveform). Capnography is
oxygen supply
particularly useful for patients who are difficult to
Discharge criteria See Appendix 1 See Appendix 1 observe (e.g., during MRI or in a darkened room).64,
67,72,90,96,110,159-162,164-170,372-375

The physician/dentist or his or her designee shall document or depression. Particular weight-based attention should be
the name, route, site, time of administration, and dosage of all paid to cumulative dosage in all children. 118,120,125,383-386 To
drugs administered. If sedation is being directed by a physician ensure that the patient will not receive an excessive dose, the
who is not personally administering the medications, then maximum allowable safe dosage (e.g., mg/kg) should be
recommended practice is for the nurse administering the med- calculated before administration. There may be enhanced
ication to confirm the dose verbally before administration. The sedative effects when the highest recommended doses of
inspired concentrations of inhalation sedation agents and oxygen local anesthetic drugs are used in combination with other
and the duration of administration shall be documented. sedatives or opioids (see Tables 3 and 4 for limits and
conversion tables of commonly used local anesthetics).118,125,
387-400
Postsedation care In general, when administering local anesthetic drugs,
The facility and procedures followed for postsedation care the practitioner should aspirate frequently to minimize the
shall conform to those described under “moderate sedation.” likelihood that the needle is in a blood vessel; lower doses
The initial recording of vital signs should be docu-
mented at least every 5 minutes. Once the child
begins to awaken, the recording intervals may be Table 3. COMMONLY USED LOCAL ANESTHETIC AGENTS FOR NERVE BLOCK
increased to 10 to 15 minutes. Table 2 summarizes OR INFILTRATION: DOSES, DURATION, AND CALCULATIONS
the equipment, personnel, and monitoring require-
Local anesthetic Maximum dose with Maximum dose without Duration of
ments for moderate and deep sedation. a b
Epinephrine (mg/kg) Epinephrine (mg/kg) action
(min)
Special considerations Medical Dental Medical Dental
Neonates and former preterm infants Esters
Neonates and former preterm infants require specific
Procaine 10 6 7 6 60-90
management, because immaturity of hepatic and
Chloroprocaine 20 12 15 12 30-60
renal function may alter the ability to metabolize and
excrete sedating medications,376 resulting in prolonged Tetracaine 1.5 1 1 1 180-600
sedation and the need for extended postsedation Amides
monitoring. Former preterm infants have an increased
Lidocaine 7 4.4 4 4.4 90-200
risk of postanesthesia apnea, 377 but it is unclear
whether a similar risk is associated with sedation, Mepivacaine 7 4.4 5 4.4 120-240
because this possibility has not been systematically Bupivacaine 3 1.3 2.5 1.3 180-600
investigated.378 Levobupivacaine c 3 2 2 2 180-600
Other concerns regarding the effects of anesthetic Ropivacaine 3 2 2 2 180-600
drugs and sedating medications on the developing Articaine d _ 7 _ 7 60-230
brain are beyond the scope of this document.
At this point, the research in this area is preliminary Maximum recommended doses and durations of action are shown. Note that lower doses should be
and inconclusive at best, but it would seem prudent used in very vascular areas.
a These are maximum doses of local anesthetics combined with epinephrine; lower doses are recom-
to avoid unnecessary exposure to sedation if the
mended when used without epinephrine. Doses of amides should be decreased by 30% in infants
procedure is unlikely to change medical/dental man- younger than 6 mo. When lidocaine is being administered intravascularly (e.g., during intravenous
agement (e.g., a sedated MRI purely for screening regional anesthesia), the dose should be decreased to 3 to 5 mg/kg; long-acting local anesthetic
purposes in preterm infants).379-382 agents should not be used for intravenous regional anesthesia.
b Duration of action is dependent on concentration, total dose, and site of administration; use of
Local anesthetic agents epinephrine; and the patient’s age.
All local anesthetic agents are cardiac depressants c Levobupivacaine is not available in the United States.
and may cause central nervous system excitation d Use in pediatric patients under 4 years of age is not recommended.
Table 4. LOCAL ANESTHETIC Table 5. TREATMENT OF LOCAL ANESTHETIC TOXICITY

CONVERSION CHART
Concentration (%) mg/mL 1. Get help. Ventilate with 100% oxygen. Alert nearest facility with cardiopulmonary bypass capability.
2. Resuscitation: airway/ventilatory support, chest compressions, etc. Avoid vasopressin, calcium channel blockers,
4.0 40 ß-blockers, or additional local anesthetic. Reduce epinephrine dosages. Prolonged effort may be required.
3.0 30 3. Seizure management: benzodiazepines preferred (e.g., intravenous midazolam 0.1–0.2 mg/kg); avoid propofol
if cardiovascular instability.
2.5 25
4. Administer 1.5 mL/kg 20% lipid emulsion over ~ 1 minute to trap unbound amide local anesthetics. Repeat
2.0 20 bolus once or twice for persistent cardiovascular collapse.
1.0 10 5. Initiate 20% lipid infusion (0.25 mL/kg per minute) until circulation is restored; double the infusion rate if
blood pressure remains low. Continue infusion for at least 10 minutes after attaining circulatory stability.
0.5 5
Recommended upper limit of ~10 mL/kg.
0.25 2.5
6. A fluid bolus of 10–20 mL/kg balanced salt solution and an infusion of phenylephrine (0.1 μg/kg per minute
0.125 1.25 to start) may be needed to correct peripheral vasodilation.
Source: https://www.asra.com/advisory-guidelines/article/3/checklist-for-treatment-of-local-anesthetic-systemic-toxicity.

should be used when injecting into vascular tissues.401 If high of propofol sedation, the numbers may paradoxically go up
doses or injection of amide local anesthetics (bupivacaine and rather than down with sevoflurane and ketamine because of
ropivacaine) into vascular tissues is anticipated, then the central excitation despite a state of general anesthesia or deep
immediate availability of a 20% lipid emulsion for the sedation.429,430 Opioids and benzodiazepines have minimal and
treatment of local anesthetic toxicity is recommended (Tables variable effects on the BIS. Dexmedetomidine has minimal
3 and 5). 402-409 Topical local anesthetics are commonly used effect with EEG patterns, consistent with stage 2 sleep.431 Several
and encouraged, but the practitioner should avoid applying sedation studies have examined the utility of this device and
excessive doses to mucosal surfaces where systemic uptake and degree of correlation with standard sedation scales.347,363,432-435 It
possible toxicity (seizures, methemoglobinemia) could result appears that there is some correlation with BIS values in mod-
and to remain within the manufacturer’s recommendations erate sedation, but there is not a reliable ability to distinguish
regarding allowable surface area application.410-415 between deep sedation and moderate sedation or deep sedation
from general anesthesia.432 Presently, it would appear that BIS
Pulse oximetry monitoring might provide useful information only when used
Newer pulse oximeters are less susceptible to motion artifacts for sedation with propofol363; in general, it is still considered
and may be more useful than older oximeters that do not a research tool and not recommended for routine use.
contain updated software. 416-420 Oximeters that change tone
with changes in hemoglobin saturation provide immediate aural Adjuncts to airway management and resuscitation
warning to everyone within hearing distance. The oximeter The vast majority of sedation complications can be managed
probe must be properly positioned; clip-on devices are easy to with simple maneuvers, such as supplemental oxygen, opening
displace, which may produce artifactual data (under- or over- the airway, suctioning, placement of an oral or nasopharyngeal
estimation of oxygen saturation).361,362 airway, and bag-mask-valve ventilation. Rarely, tracheal intu-
bation is required for more prolonged ventilatory support. In
Capnography addition to standard tracheal intubation techniques, a number
Expired carbon dioxide monitoring is valuable to diagnose the of supraglottic devices are available for the management of
simple presence or absence of respirations, airway obstruction, patients with abnormal airway anatomy or airway obstruction.
or respiratory depression, particularly in patients sedated in Examples include the LMA, the cuffed oropharyngeal airway,
less-accessible locations, such as in MRI machines or darkened and a variety of kits to perform an emergency cricothyrotomy.436,437
rooms. 64,66,67,72,90,96,110,159-162,164-170,372-375,421-427 In patients recei- The largest clinical experience in pediatrics is with the
ving supplemental oxygen, capnography facilitates the recog- LMA, which is available in multiple sizes, including those for
nition of apnea or airway obstruction several minutes before late preterm and term neonates. The use of the LMA is now
the situation would be detected just by pulse oximetry. In an essential addition to advanced airway training courses, and
this situation, desaturation would be delayed due to increased familiarity with insertion techniques can be life-saving. 438-442
oxygen reserves; capnography would enable earlier interven- The LMA can also serve as a bridge to secure airway manage-
tion.161 One study in children sedated in the emergency dement in children with anatomic airway abnormalities. 443,444
partment found that the use of capnography reduced the Practitioners are encouraged to gain experience with these
incidence of hypoventilation and desaturation (7% to 1%).174 techniques as they become incorporated into PALS courses.
The use of expired carbon dioxide monitoring devices is now Another valuable emergency technique is intraosseous
required for almost all deeply sedated children (with rare needle placement for vascular access. Intraosseous needles are
exceptions), particularly in situations in which other means available in several sizes; insertion can be lifesaving when rapid
of assessing the adequacy of ventilation are limited. Several intravenous access is difficult. A relatively new intraosseous
manufacturers have produced nasal cannulae that allow simul-
taneous delivery of oxygen and measurement of expired carbon
®
device (EZ-IO Vidacare, now part of Teleflex, Research
Triangle Park, N.C.) is similar to a hand-held battery-powered
dioxide values.421,422,427 Although these devices can have a high drill. It allows rapid placement with minimal chance of mis-
degree of false-positive alarms, they are also very accurate for placement; it also has a low-profile intravenous adapter.445-450
the detection of complete airway obstruction or apnea.164,168,169 Familiarity with the use of these emergency techniques can be
Taping the sampling line under the nares under an oxygen face gained by keeping current with resuscitation courses, such as
mask or nasal hood will provide similar information. The exact PALS and advanced pediatric life support.
measured value is less important than the simple answer to
the question: Is the child exchanging air with each breath? Patient simulators
High-fidelity patient simulators are now available that allow
Processed EEG (Bispectral Index) physicians, dentists, and other health care providers to practice
Although not new to the anesthesia community, the processed managing a variety of programmed adverse events, such as
EEG (bispectral index [BIS]) monitor is slowly finding its way apnea, bronchospasm, and laryngospasm. 133,220,450-452 The use
into the sedation literature.428 Several studies have attempted of such devices is encouraged to better train medical professionals
to use BIS monitoring as a means of noninvasively assessing and teams to respond more effectively to rare events. 128,131,
451,453-455
the depth of sedation. This technology was designed to examine One study that simulated the quality of cardiopul-
EEG signals and, through a variety of algorithms, correlate a monary resuscitation compared standard management of
number with depth of unconsciousness: that is, the lower the
number, the deeper the sedation. Unfortunately, these algor-
®
ventricular fibrillation versus rescue with the EZ-IO for the
rapid establishment of intravenous access and placement of
ithms are based on adult patients and have not been validated an LMA for establishing a patent airway in adults; the use of
in children of varying ages and varying brain development. these devices resulted in more rapid establishment of vascular
Although the readings correspond quite well with the depth access and securing of the airway.456

Monitoring during MRI hydrate, midazolam, or an opioid, or if nitrous oxide is used

The powerful magnetic field and the generation of radiofre- in concentrations >50%, the likelihood for moderate or deep
quency emissions necessitate the use of special equipment to sedation increases. 107,197,492,494,495 In this situation, the practi-
provide continuous patient monitoring throughout the MRI tioner is advised to institute the guidelines for moderate or
scanning procedure. 457-459 MRI-compatible pulse oximeters deep sedation, as indicated by the patient’s response.496
and capnographs capable of continuous function during scan-
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Supplemental Information
Appendix 1. Recommended Discharge Criteria Appendix 3. Drugs† That May Be Needed
1. Cardiovascular function and airway patency are satisfac- to Rescue a Sedated Patient 44
tory and stable. Albuterol for inhalation
2. The patient is easily arousable, and protective airway Amiodarone
reflexes are intact. Ammonia spirits
3. The patient can talk (if age appropriate). Atropine
4. The patient can sit up unaided (if age appropriate). Dextrose (D25)
5. For a very young child or a child with disability who is Diphenhydramine
incapable of the usually expected responses, the preseda- Diazepam
tion level of responsiveness or a level as close as possible Epinephrine (1:1000, 1:10 000)
to the normal level for that child should be achieved. Fentanyl
6. The state of hydration is adequate. Flumazenil
Lidocaine (cardiac lidocaine, local infiltration)
Lorazepam
Appendix 2. ASA Physical Status Classification* Methylprednisolone
Class I A normally healthy patient. Midazolam
Class II A patient with mild systemic disease (e.g., Naloxone
controlled reactive airway disease). Oxygen
Class III A patient with severe systemic disease (e.g., a child Fosphenytoin
who is actively wheezing).
Class IV A patient with severe systemic disease that is a Racemic epinephrine
constant threat to life (e.g., a child with status Rocuronium
asthmaticus). Sodium bicarbonate
Class V A moribund patient who is not expected to survive Succinylcholine
without the operation (e.g., a patient with severe 20% Lipid emulsion for local anesthetic toxicity
cardiomyopathy requiring heart transplantation).
† The choice of emergency drugs may vary according to individual
An “E” after the classification would indicate that this is an or procedural needs.
emergency rather than a scheduled patient.
* Modified to give common pediatric examples; full definitions are Appendices continued on the next page.
available at: “https://www.asahq.org/clinical/physicalstatus.htm”.

Appendix 4. Emergency Equipment That May Be Needed to Rescue a Sedated Patient †,‡
Intravenous Equipment Airway Management Equipment

Assorted intravenous catheters (e.g., 24-, 22-, 20-, 18-, Face masks (infant, child, small adult, medium adult,
16-gauge) large adult)
Tourniquets Breathing bag and valve set
Alcohol wipes Oropharyngeal airways (infant, child, small adult, medium
Adhesive tape adult, large adult)
Assorted syringes (e.g., 1 mL, 3 mL, 5 mL, 10 mL, Nasopharyngeal airways (small, medium, large)
20 mL, and 60 mL) Laryngeal mask airways (1, 1.5, 2, 2.5, 3, 4, and 5)
Intravenous tubing Laryngoscope handles (with extra batteries)
Pediatric drip (60 drops/mL) Laryngoscope blades (with extra light bulbs)
Pediatric burette Straight (Miller) No. 1, 2, and 3
Adult drip (10 drops/mL) Curved (Macintosh) No. 2 and 3
Extension tubing Endotracheal tubes
Three-way stopcocks 2.5, 3.0, and 3.5 mm internal diameter uncuffed and
Intravenous fluid 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 7.0, and 8.0 mm
Lactated Ringer solution internal diameter cuffed (a cuffed tracheal tube 0.5
Normal saline solution size smaller than an uncuffed tube may be used in
D5 0.25 normal saline solution children >3 months)
Pediatric intravenous boards Stylettes (appropriate sizes for endotracheal tubes)
Assorted intravenous needles: 25-, 22-, 20-, and 18-gauge Surgical lubricant
Intraosseous needles Suction catheters (appropriate sizes for endotracheal tubes)
Sterile gauze pads Yankauer-type suction
Nasogastric tubes
† The choice of emergency drugs may vary according to individual Nebulizer with medication kits
or procedural needs. Gloves (sterile and nonsterile, latex free)
‡ The practitioner is referred to the SOAPME acronym described in
the text in preparation for sedating a child for a procedure.

BEST PRACTICES: USE OF ANESTHESIA PROVIDERS
Use of Anesthesia Providers in the Administration

of Office-based Deep Sedation/General Anesthesia
to the Pediatric Dental Patient
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Use of anes-
2019* thesia providers in the administration of office-based deep sedation/
general anesthesia to the Pediatric Dental Patient. The Reference
Purpose children, adolescents, and persons with special health care needs
The American Academy of Pediatric Dentistry (AAPD) in a manner that promotes excellence in quality of care and
recognizes that there are pediatric dental patients for whom concurrently induces a positive attitude in the patient toward
routine dental care using non-pharmacologic behavior guidance dental treatment. Behavior guidance techniques have allowed
techniques is not a viable approach.1 The AAPD intends this most pediatric dental patients to receive treatment in the dental
guideline to assist the dental practitioner who elects to use a office with minimal discomfort and without expressed fear.
licensed anesthesia provider for the administration of deep Minimal or moderate sedation has allowed others who are less
sedation/general anesthesia for pediatric dental patients in a compliant to receive treatment. Some children and individuals
dental office or other facility outside of an accredited hospital with special care needs who have extensive oral healthcare
or ambulatory surgical center. This document discusses person- needs, acute situational anxiety, uncooperative age-appropriate
nel, facilities, documentation, and quality assurance mechanisms behavior, immature cognitive functioning, disabilities, or
necessary to provide optimal and responsible patient care. medical conditions require deep sedation/general anesthesia to
receive dental treatment in a safe and humane fashion.3 Access
Methods to hospital-based anesthesia services may be limited for a variety
Recommendations on the use of anesthesia providers in of reasons, including restriction of coverage of by third-party
the administration of office-based deep sedation/general payors.3,4 Pediatric dentists and others who treat children can
anesthesia were developed by the Clinical Affairs Committee provide for the administration of deep sedation/general anes-
– Sedation and General Anesthesia Subcommittee and thesia by utilizing properly trained and currently licensed
adopted in 2001. This document is a revision of the previ- anesthesia providers in their offices or other facilities outside
ous version, last revised in 2018. The modification by the of the traditional surgical setting.
Council of Clinical Affairs is limited to the section on person- Office-based deep sedation/general anesthesia can provide
nel, with changes based upon a review of the recently revised benefits for the patient and the dental team. Such benefits
Guidelines for Monitoring and Management of Pediatric Pa- may include:
tients Before, During, and After Sedation for Diagnostic and • improved access to care;
Therapeutic Procedures2, a joint publication of the AAPD and • improved ease and efficiency of scheduling;
the American Academy of Pediatrics. The last full revision • decreased administrative procedures and facility fees
utilized current dental and medical literature pertaining to when compared to a surgical center or hospital;
deep sedation/general anesthesia of dental patients, including • minimized likelihood of patient’s recall of procedures;
®
a search of the PubMed /MEDLINE database using the
terms: office-based general anesthesia, pediatric sedation, deep
• decreased patient movement which may optimize quality
of care; and
sedation, sleep dentistry, and dental sedation; fields: all; limits: • use of traditional dental delivery systems with access to
humans, all children from birth through age 18, English, a full complement of dental equipment, instrumentation,
clinical trials, and literature reviews. When data did not supplies, and auxiliary personnel.
appear sufficient or were inconclusive, recommendations were
based upon expert and/or consensus opinion by experienced
researchers and clinicians. ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. APLS: Advanced
Background pediatric life support. ASA: American Society of Anesthesiologists.
Pediatric dentists seek to provide oral health care to infants, CAA: Certified anesthesiologst assistant. CO2: Carbon dioxide. CRNA:
Certified registered nurse anesthetist. PALS: Pediatric advanced life
support.
* The 201 9 revision was limited to section on personnel.

The use of licensed anesthesia providers to administer deep (CRNA) or certified anesthesiologist assistant (CAA) to
sedation/general anesthesia in the pediatric dental population function under the direct supervision of a dentist, the
is an accepted treatment modality.2,5-8 Caution must be used in dentist is required to have completed training in deep
patients younger than two years of age. Practitioners must sedation/general anesthesia and be licensed or permitted
always be mindful of the increased risk associated with office- for that level of pharmacologic management, appropriate
based deep sedation/general anesthesia in the infant and to state law. Furthermore, to maximize patient safety,
toddler populations. This level of pharmacologic behavioral the dentist supervising the CRNA or CAA would not
modification should only be used when the risk of orofacial simultaneously be providing dental treatment. The
disease outweighs the benefits of monitoring, interim thera- CRNA or CAA must be licensed with current state certi-
peutic restoration, or arresting medicaments to slow or stop fication to administer deep sedation/general anesthesia
the progression of caries. The AAPD supports the provision of in a dental office. He/She must be in compliance with
deep sedation/general anesthesia when clinical indications have state and local laws regarding anesthesia practices. Laws
been met and additional properly-trained and credentialed vary from state to state and may supersede any portion
personnel and appropriate facilities are used.1-3 In many cases, of this document.
the patient may be treated in an appropriate outpatient facility
(including the dental office) because the extensive medical The dentist and anesthesia care provider must be compliant
resources of a hospital may not be deemed necessary for deliv- with the American Academy of Pediatrics/AAPD’s Guideline
ering routine health care. on Monitoring and Management of Pediatric Patients Before,
During, and After Sedation for Diagnostic and Therapeutic
Recommendations Procedures 2 or other appropriate guideline(s) of the American
Clinicians may consider using deep sedation or general anes- Dental Association, the American Society of Dental Anesthesi-
thesia in the office to facilitate the provision of oral health ologists (ASDA), the American Society of Anesthesiologists
care. Practitioners choosing to use these modalities must be (ASA), and other organizations with recognized professional
trained in rescue emergency procedures and be familiar with expertise and stature. The recommendations in this document
their patient’s medical history, as well as the regulatory and may be exceeded at any time if the change involves improved
professional liability insurance requirements needed to provide safety and/or is superseded by state law.
this level of pharmacologic behavior management. This The dentist and licensed anesthesia provider must collaborate
guideline does not supersede, nor is it to be used in deference to enhance patient safety. Continuous and effective periopera-
to, federal, state, and local credentialing and licensure laws, tive communication and appropriately timed interventions are
regulations, and codes. essential in mitigating adverse events or outcomes. The dentist
introduces the concept of deep sedation/general anesthesia to
Personnel the parent, justifies its necessity, and provides appropriate pre-
Deep sedation/general anesthesia techniques in the dental operative instructions and informational materials. The dentist
office require the presence of the following individuals or his/her designee coordinates medical consultations when
throughout the procedure2: necessary and conveys pertinent information to the anesthesia
• licensed anesthesia provider who is independent of care provider. The anesthesia care provider explains potential
performing or assisting with the dental procedure; and risks and obtains informed consent for sedation/anesthesia.
• operating dentist. Office staff should understand their additional roles and
responsibilities and special considerations (e.g., loss of protec-
It is the exclusive responsibility of the operating dentist, tive reflexes) associated with office-based deep sedation/general
when employing anesthesia providers to administer deep anesthesia.
sedation/general anesthesia, to verify and carefully review Both the licensed anesthesia provider and the operating
their credentials and experience. Significant pediatric training, dentist must, at a minimum, have appropriate training and
including anesthesia care of the very young, and experience up-to-date certification in patient rescue, including drug
in a dental setting are important considerations, especially administration and pediatric advanced life support (PALS) or
when caring for young pediatric and special needs populations. advanced pediatric life support (APLS).2 The licensed anes-
In order to provide anesthesia services in an office-based thesia provider’s sole responsibility is to administer drugs and
setting: constantly monitor and record the patient’s vital signs, depth
• the licensed anesthesia provider must be a licensed dental of sedation, airway patency, and adequacy of ventilation.2 The
and/or medical practitioner with current state certifica- anesthesia provider must be skilled to establish intravenous
tion to independently administer deep sedation/general access and draw up and administer rescue medications, He
anesthesia in a dental office. He/She must be in com- must have the training and skills to rescue a child with apnea,
pliance with state and local laws regarding anesthesia laryngospasm, airway obstruction, hypotension, anaphylaxis, or
practices. Laws vary from state to state and may supersede cardiopulmonary arrest, including the ability to open the airway,
any portion of this document. suction secretions, provide constant positive airway pressure
• if state law permits a certified registered nurse anesthetist (CPAP), insert supraglottic devices (oral airway, nasal trumpet,

or laryngeal mask airway), and perform successful bag-valve- and occupancy, accommodations for the disabled, occupational
mask ventilation, tracheal intubation, and cardiopulmonary safety and health, and disposal of medical waste and hazardous
resuscitation.2 As permitted by state regulation, the anesthesia waste.2 The treatment room must accommodate the dentist and
provider may be one of the following: auxiliaries, the patient, the anesthesia care provider, the dental
• dentist or physician anesthesiologist; equipment, and all necessary anesthesia delivery equipment
• certified registered nurse anesthetist; or along with appropriate monitors and emergency equipment. Ex-
• an oral and maxillofacial surgeon. peditious access to the patient, anesthesia machine (if present),
and monitoring equipment should be available at all times.
The anesthesia provider would assume the lead during the It is beyond the scope of this document to dictate equipment
management of any perioperative emergencies. The dentist must necessary for the provision of deep sedation/general anesthesia,
be capable of providing skilled assistance with the rescue of a but equipment must be appropriate for the technique used
child experiencing any of the adverse events described above.2 and consistent with the guidelines for anesthesia providers, in
It is the responsibility of the anesthesia provider to ensure that accordance with governmental rules and regulations. Because
the operating dentist and supportive staff are capable of pro- laws and codes vary from state to state, Guidelines for Monitor-
viding skilled support and have an established emergency and ing and Management of Pediatric Patients Before, During, and
transport protocol in the event of an adverse incident. After Sedation for Diagnostic and Therapeutic Procedures 2 should
Personnel experienced in post anesthetic recovery care and be followed as the minimum requirements.
trained in advanced resuscitative techniques (e.g., PALS) must For deep sedation/general anesthesia, there must be contin-
be in attendance and provide continuous respiratory and uous monitoring of the patient’s level of consciousness and
cardiovascular monitoring during the recovery period.2 The responsiveness, heart rate, blood pressure, respiratory rate,
supervising anesthesia provider, not the operating dentist, shall expired carbon dioxide (CO2) values, and oxygen saturation.2
determine when the patient exhibits respiratory and cardio- When adequacy of ventilation is difficult to observe using
vascular stability and appropriate discharge criteria2 have been capnography, use of an amplified, audible precordial stetho-
met. The operating dentist must have up-to-date certification
in PALS or APLS, and his/her clinical staff must be well-versed
®
scope (e.g., Bluetooth technology) is encouraged.2 In addition,
an electrocardiographic monitor and a defibrillator capable of
in emergency recognition, rescue, and emergency protocols in- delivering an attenuated pediatric dose are required for deep
cluding maintaining cardiopulmonary resuscitation certification sedation/general anesthesia.2 Emergency equipment must be
for healthcare providers.6 Contact numbers for local emergency readily accessible and should include Yankauer suction, drugs
medical and ambulance services must be readily available, and necessary for rescue and resuscitation (including 100 percent
a protocol for immediate access to back-up emergency services oxygen capable of being delivered by positive pressure at appro-
must be clearly outlined.2 Emergency preparedness must be priate flow rates for up to one hour), and age-/size-appropriate
updated and practiced on a regular (e.g., semi-annual) basis equipment to resuscitate and rescue a non-breathing and/or
to keep all staff members up to date on established protocols unconscious pediatric dental patient and provide continuous
(see Table).9 support while the patient is being transported to a medical
facility.2,5 The licensed practitioners are responsible for ensur-
Facilities ing that medications, equipment, and protocols are available to
A continuum extends from wakefulness across all levels of treat malignant hyperthermia when triggering agents are used.11
sedation. Often these levels are not easily differentiated, and Recovery facilities must be available and suitably equipped.
patients may drift among them.10 When anesthesia care Backup power sufficient to ensure patient safety should be
providers are utilized for office-based administration of deep available in case of emergency power outage.2
sedation or general anesthesia, the facilities in which the dentist
practices must meet the guidelines and appropriate local, state, Documentation
and federal codes for administration of the deepest possible Prior to delivery of deep sedation/general anesthesia, patient
level of sedation/anesthesia. Facilities must be in compliance safety requires that appropriate documentation shall address
with applicable laws, codes, and regulations pertaining to rationale for sedation/general anesthesia, anesthesia and proce-
controlled drug storage, fire prevention, building construction dural informed consent, instructions to parent, dietary
Table. CONSIDERATIONS IN FREQUENCY OF CONDUCTING EMERGENCY EXERCISES 9
Changes in plans Changes in the emergency response plan need to be disseminated and practiced.
Changes in personnel New staff members need training in their emergency response roles. Emergency roles left by former staff members need to be filled.
Changes in property Infrastructure changes can affect how the plan is implemented. New equipment may require training for their use.
Foreseen problems Protocols for newly identified problems must be established, practiced and implemented.
Reprinted from Guidance Materials: Hospital and Health Facility Emergency Exercises, Emergency exercise basics, Page 4, Copyright © World Health Organization 2010.
Available at: “http://www.wpro.who.int/publications/PUB_9789290614791/en/”. Accessed October 10, 2019.

precautions, preoperative health evaluation, and any prescrip- References

tions along with the instructions given for their use.2 Because 1. American Academy of Pediatric Dentistry. Behavior
laws and codes vary from state to state, Guidelines on guidance for the pediatric dental patient. Pediatr Dent
Monitoring and Management of Pediatric Patients Before, During, 2018;40(6):254-67.
and After Sedation for Diagnostic and Therapeutic Procedure 2 2. Coté CJ, Wilson S, American Academy of Pediatrics,
should be followed as minimum requirements for a time-based American Academy of Pediatric Dentistry. Guidelines for
anesthesia record. monitoring and management of pediatric patients before,
• Vital signs: Pulse and respiratory rates, blood pressure, during, and after sedation for diagnostic and therapeutic
heart rhythm, oxygen saturation, and expired CO2 must procedures. Pediatr Dent 2019;41(4):E26-E52.
be continuously monitored and recorded on a time-based 3. Glassman P, Caputo A, Dougherty N, et al. Special Care
record throughout the procedure, initially every five min- Dentistry Association consensus statement on sedation,
utes and then, as the patient awakens, at 10-15 minute anesthesia, and alternative techniques for people with spe-
intervals until the patient has met documented discharge cial needs. Spec Care Dentist 2009;29(1):2-8; quiz 67-8.
criteria.2 4. American Academy of Pediatric Dentistry. Policy on
• Drugs: Name, dose, route, site, time of administration, third-party reimbursement of medical fees related to
and patient effects (e.g., level of consciousness, patient sedation/general anesthesia for delivery of oral health
responsiveness) of all drugs, including local anesthesia, care services. Pediatr Dent 2018;40(6):117-9.
must be documented.2 When anesthetic gases are admin- 5. American Society of Anesthesiologists. Guidelines for
istered, inspired concentration and duration of inhalation office-based anesthesia. 2009. Reaffirmed 2014. Available
agents and oxygen shall be documented.2 at: “http://www.asahq.org/~/media/Sites/ASAHQ/Files/
Public/Resources/standards-guidelines/guidelines-for-
• Recovery: The condition of the patient, that discharge
office-based-anesthesia.pdf ”. Accessed March 22, 2017.
criteria have been met, time of discharge, and into whose
care the discharge occurred must be documented. Re-
6p9jMa4Aj”)
®
quiring the signature of the responsible adult to whom
6. American Dental Association. Guidelines for the use of
the child has been discharged, verifying that he/she has sedation and general anesthesia by dentists. 2016. Avail-
received and understands the post-operative instructions, able at: “http://www.ada.org/en/~/media/ADA/Advocacy/
is encouraged.2 Files/anesthesia_use_guidelines”. Accessed March 22,
Various business/legal arrangements may exist between citation.org/6p9ddeDFJ”)
®
the treating dentist and the anesthesia provider. Regardless, 7. Nick D, Thompson L, Anderson D, Trapp L. The use
because services were provided in the dental facility, the dental of general anesthesia to facilitate dental treatment. Gen
staff must maintain all patient records, including time-based Dent 2003;51(5):464-8.
anesthesia records, so that they may be readily available for 8. Wilson S. Pharmacologic behavior management for
emergency or other needs. The dentist must assure that the pediatric dental treatment. Pediatr Clin North Am 2000;
anesthesia provider also maintains patient records and that 47(5):1159-73.
they are readily available. 9. World Health Organization. Hospital and health facility
emergency exercises. Guidance materials. WHO Press,
Risk management and quality assurance 2010. Available at: “http://www.wpro.who.int/publica
Dentists who utilize office-based anesthesia care providers tions/PUB_9789290614791/en/”. Accessed September
must take all necessary measures to minimize risk to patients.
The dentist must be familiar with the ASA physical status
®
citation.org/6tb70x1pr”)
classification.12 Knowledge, preparation, and communication 10. Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog
between professionals are essential. Prior to subjecting a JH, Pediatric Sedation Research Consortium. The
patient to deep sedation/general anesthesia, the patient must incidence and nature of adverse events during pediatric
undergo a pre-operative health evaluation by an appropriate sedation/anesthesia with propofol for procedures outside
and currently licensed medical or anesthesia provider.2,6 High- the operating room; A report from the Pediatric Sedation
risk patients should be treated in a facility properly equipped Research Consortium. Anesth Analg 2009;108(3):795-804.
and staffed to provide for their care.2,6 The dentist and 11. Rosenberg H. Succinylcholine dantrolene controversy:
anesthesia care provider must communicate during treatment President’s report. Malignant Hyperthermia Association
to share concerns about the airway or other details of patient of the United States. Available at: “http://www.mhaus.org
safety. Furthermore, they must work together to develop and /blog/post/a8177/succinylcholine-dantrolene-controversy”.
document mechanisms of quality assurance. Accessed March 22, 2017. (Archived by WebCite at:
“http://www.webcitation.org/6p9jqQ0WO”)
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Untoward and unexpected outcomes must be documented
and reviewed to monitor the quality of services provided. 12. American Society of Dentist Anesthesiologists. ASA
This will decrease risk, allow for open and frank discussions, physical status classification system. Available at: “https:
document risk analysis and intervention, and improve the //www.asahq.org/resources/clinical-information/asa-
quality of care for the pediatric dental patient.2,5 physical-status-classification-system”. Accessed March 22,
®
tion.org/6p9jx3iGg”)

BEST PRACTICES: PAIN MANAGEMENT
Pain Management in Infants, Children, Adolescents,

and Individuals with Special Health Care Needs
Adopted How to Cite: American Academy of Pediatric Dentistry. Pain
2018 management in infants, children, adolescents, and individuals with
special health care Needs. The Reference Manual of Pediatric
2020:362-70.
Purpose pharmacologic and nonpharmacologic strategies to treat both

The American Academy of Pediatric Dentistry (AAPD) acute and chronic pain. Due to the increased appreciation for
recognizes that infants, children, adolescents, and individuals pediatric pain and because of the national opioid crisis, rec-
with special health care needs can and do experience pain ommendations for professional education and approaches for
due to dental/orofacial injury, infection, and dental procedures, therapeutic management are being reviewed at the national,
and that inadequate pain management may have significant state, and local levels.2-5 This document discusses pain proces-
physical and psychological consequences for the patient. sing, pain assessment, pain categories, pre-emptive analgesia,
Appreciation of pediatric pain can help practitioners develop non-pharmacologic pain management, pharmacologic pain
clinical approaches to prevent or substantially relieve dental management, and best practices for prescribing opioids.
pain. When pharmacological intervention is necessary to man-
age pain, the practitioner must understand the consequences, Pain processing
morbidities, and toxicities associated with the use of specific Understanding pain processing is essential for the management
therapeutic agents. These recommendations are intended to of pain. Pain experience in childhood may shape future pain
provide dental professionals and other stakeholders with cur- experiences in adulthood.6 Dental pain is an inflammatory
rent best practices for pain management in pediatric dentistry. condition resulting from tissue damage, infection, or invasive
treatment.7 Swelling, hyperthermia, and activation of biochem-
Methods ical cascades are hallmarks of inflammatory pain.7,8 Thermal,
This document was developed by the Council on Clinical mechanical, and chemical stimuli activate free nerve endings.9,10
Affairs and is based on a review of current dental and medical Sensory signals travel along afferent trigeminal nerve fibers and
literature pertaining to pain management in pediatric dental relay information to the brainstem and higher structures in-
patients. Review of existing federal and professional pain volved with the perception of pain.11 Under normal conditions
management guidelines and consensus statements were used the perception of pain persists until the stimulus is removed.
to assist with this document. An electronic search was con-
®
ducted in the PubMed /MEDLINE database using the
terms: dental pain management, pediatric pain assessment, pre-
Peripheral sensitization
Terminal nerve endings at the site of tissue injury exhibit an
emptive analgesia, pediatric and acetaminophen, adolescent and enhanced neuronal response.9 This local increase in nerve
acetaminophen, pediatric and nonsteroidal anti-inflammatory membrane excitability is referred to as peripheral sensitiza-
drugs (NSAIDs), adolescent and NSAIDs, pediatric and opioids, tion.12 The exaggerated response to stimuli in the region of
adolescent and opioids, opioid risk, adolescent orofacial pain, tissue damage is called primary hyperalgesia.11
pediatric and adolescent chronic pain, non-pharmacologic
pain management; fields: all; limits: within the last 10 years, Central sensitization
humans, English, and clinical trials. There were 1395 articles Central sensitization refers to enhanced functional status of
met these criteria. Papers for review were chosen from this list pain circuits and pain processing at the level of the central
and from references within selected articles. When data did nervous system (CNS).8,12,13 Both secondary hyperalgesia, which
not appear sufficient or were inconclusive, recommendations
were based upon expert and/or consensus opinion by expe-
rienced researchers and clinicians. ABBREVIATIONS
Background of Pediatric Dentistry. APAP: Acetyl-para-aminophenol. APS:
Pain is defined by the International Association of the Study American Pain Society. CDC: Centers for Disease Control and Pre-
vention. CNS: Central nervous system. FDA: U.S. Food and Drug
of Pain as “an unpleasant sensory and emotional experience
Administration. IV: Intravenous. NSAIDs: Nonsteroidal anti-
associated with actual or potential tissue damage or described inflammatory drugs. VAS: Visual analogue scale.
in terms of such damage.”1 Pain management includes

is an increase in pain intensity to noxious stimuli outside of pain management include attenuating central sensitization, de-
the area of tissue damage, and allodynia, which refers to pain creasing postoperative pain, improving recovery, and reducing
perception following innocuous stimuli such as light touch, postoperative analgesic consumption.11,15 Postoperative pain
are characteristics of central sensitization.13 management in pediatric patients has been suboptimal in
large part because of the misconception that children do not
Pain modulation feel pain as severely as adults do34 and the fear of adverse
Modulation of pain pathways occurs through CNS excitatory events.35 It has been shown that nearly 50 percent of patients
and inhibitory processes. Ascending facilitating and descending undergoing dental rehabilitation describe moderate to severe
inhibitory processes enhance or suppress the pain experience, pain36, and there is data to support pre-emptive measures to
respectively.12 Both pharmacologic and nonpharmacologic optimize pain control for a variety of dental and surgical pro-
methods target these processes to alter pain processing.14,15 cedures.37 However, level of evidence is low due to sparse
well-controlled trials.38-40
Pain assessment Achieving profound anesthesia prior to initiating treatment
Ethnic, cultural, and language factors may influence expression decreases central sensitization.37 Topical anesthetics are used in
and assessment of pain.16 Pain is assessed using self-report, a dentistry to minimize pain; however, these medicaments
behavioral (vocalization, facial expression, body movement), alone may not be sufficient for dental procedures.41,42 Other
and biological (heart rate, transcutaneous oxygen, sweating, factors that may contribute to a patient’s pain experience are
stress response) measures.17 Direct questioning or a structured, the anesthetic properties and the needle used during the
comprehensive pain assessment can be clinically beneficial for injection.43 Distraction techniques made at the time of the
pediatric and adolescent patients.17,18 Conducting a structured injection such as jiggling the patient’s cheek take advantage
interview begins with asking specific questions regarding pain of Aß-fiber signal dominance and can significantly reduce the
onset, provoking factors, palliative factors, quality or character, intensity of pain-related C-fiber signaling.43 Buffering or
region or location, severity or intensity, timing or duration, decreasing acidity of local anesthetic using sodium bicarbonate
and impact on daily activities. Obtaining information through can decrease injection site pain and postoperative discomfort
self-report can be aided by asking the child to make compari- by increasing the pH of the anesthetic. This is a well-accepted
sons, using temporal anchors and facilitating communication technique in medicine but has not been commonly used in
through objects or gestures.17 Assessing behavioral reactions dentistry.43,44 Finally, decreasing anesthetic delivery rate also
and physiological reactions to pain are required in non-verbal has demonstrated pain reduction during injection.45
and young patients.17 Four- to 12-years-old patients can likely In one study, the use of pre-emptive analgesics in conjunc-
quantify pain based on a series of faces.19 Patients older than tion with local anesthetics increased the ability to achieve pulpal
seven should be able to mark pain using a visual analogue anesthesia in patients with irreversible pulpitis when compared
scale (VAS) or numeric scale.19,20 Validated instruments avail- with placebo.46 The pre-emptive analgesics most commonly
able for assessing pain in verbal or nonverbal patients include: used in dentistry are NSAIDs and acetaminophen, either alone
Faces Pain Scale (Revised), VAS, numeric rating scale, Faces, or in combination.47 Analgesics with sedative properties are
Legs, Activity, Cry, and Consolability score (FLACC), Revised often administered during the pre-, peri-, and post-operative
Faces, Legs, Activity, Cry and Consolability (r-FLACC), and periods when moderate to severe pain is anticipated.48-51
the McGill Pain Questionnaire.19,21,22
Use of local anesthesia during general anesthesia
Pain categories Although pain is not experienced during general anesthesia,
Pain may be divided into diagnostic categories such as soma- central sensitization occurs when peripheral nerves are stimu-
tic, visceral, and neuropathic.23-26 Pain encountered in dentistry lated.37,52,53 Operating without local anesthesia may result in
is typically inflammatory and categorized as somatic (i.e., priming of CNS neurons and increased future pain sensitivity.6
periodontal, alveolar, mucosal) or visceral (i.e., pulpal) pain.27 Central sensitization is minimized with pre-emptive analgesia
Pain also may be categorized as acute or chronic. Acute or anesthesia. For this reason, regional block or infiltration
pain that fails to respond to treatment may become chronic anesthesia is commonly performed prior to surgical procedures
over time.28 Chronic pain refers to pain that is dysfunctional to decrease postoperative pain.11,54,55 However, pharmacologic
and persists beyond the time for typical tissue healing.29-32 and cardiac considerations along with avoiding the numb sen-
Temporomandibular disorder (TMD) is an example of a sation and potential for self-inflicted oral trauma are reasons
chronic pain condition encountered in dentistry.33 providers may choose not to provide local anesthesia during
general anesthesia.55,56
Pain management
Pre-emptive pain management Non-pharmacologic approaches to pain management
Pre-emptive pain management refers to administration of an Studies suggest that nonpharmacologic interventions may be
anesthetic agent, medication, or technique prior to a surgical effective alone or as adjuncts to pharmacological interventions
event with the goal of decreasing pain. Goals of pre-emptive in managing procedure-related pain, anxiety, and distress with

minimal risk of adverse effects.9,57-59 Fear and anxiety activate and adolescents.66,69 There is no evidence that hypnosis alone is
circuits within the CNS that facilitate pain.29 Creating a safe, capable of producing an anesthetic effect for dental procedures;
friendly environment may help a child feel more comfortable therefore, it should always be combined with profound local
and less stressed.58,60 The American Academy of Pediatrics anesthesia.69
(AAP) and the American Pain Society (APS) recommend that
providers reduce distress-producing stimulation and provide Other techniques
a calm environment for procedures to improve pain manage- Studies have shown efficacies for pediatric pain management
ment.3 Emotional support is a key component in creating a with other techniques such as relaxation and breathing exer-
comfortable environment.61 Although there is no evidence that cises, transcutaneous electrical nerve stimulation, acupuncture,
the presence of parents decreases pain, there is data to support counterstimulation, virtual reality, and music therapies.65,67,70-75
that it may decrease the child’s anxiety and distress.60 Con- Additional research is need on these interventions to measure
versely, parental catastrophizing has been associated with poor their effectiveness.
outcomes for pediatric pain management.62 The AAP and APS
jointly advise expectation management for parents along with Pharmacologic Agents
preparation for comforting their children when pain is antici- Management of pain in children is changing rapidly as a result
pated.3 Individual studies have shown the efficacy of psycho- of improvements in the appreciation of pediatric pain and
logic techniques, including preparation and information, parent pharmacologic knowledge. However, randomized controlled
coaching or training, suggestion, memory alteration or change, trials are lacking in children so the use of many pain medica-
and coping self-statements.63-65 However, a 2013 Cochrane re- tions are still considered off label.76,77 Acetaminophen, ibupro-
view concluded that there is no strong evidence available to fen, and opioids are common medication choices for the
support the efficacy of preparation and information, combined treatment of acute pain in children.16,76
cognitive or behavioral strategies, parent coaching plus
distraction, or suggestion for reducing needle-related pain and Non-opioid analgesics
distress.66 Nonsteroidal anti-inflammatory drugs. NSAIDs are among
the most commonly used class of drugs and have anti-
Distraction and imagery inflammatory, analgesic, antipyretic, and antiplatelet properties.78
Distraction is an effective method of pain management in the They inhibit prostaglandin synthesis, with specific action on
pediatric population.16,67 It can be cognitive (e.g., counting, cyclooxygenase (COX).50 Representatives of the major
non-procedural talk) or behavioral (e.g., videos, games), both categories of NSAIDs are salicylic acids (aspirin), acetic acids
of which aim to shift attention away from pain. Distraction (ketorolac), proprionic acids (ibuprofen, naproxen), and
techniques such as bubbles, counting, conversation, music, cyclooxygenase-2 selective (celecoxib). Ibuprofen in oral or
television, toys and video games may be used by health care intravenous (IV) form is a commonly used analgesic and
providers or the child’s caregiver.58,60 There is strong evidence antipyretic agent in pediatrics.78 Ketorolac, an IV or intranasal
supporting the efficacy of distraction techniques for needle- NSAID, is useful in treating moderate to severe acute pain in
related pain and distress in children and adolescents.66 Distrac- patients unable or unwilling to swallow oral NSAIDs.26,54,79
tion has been shown to be significantly effective when Some of the adverse effects associated with NSAIDs include:
measuring pulse rates, respiratory rates, and self-reported inhibition of bone growth and healing, gastritis with pain and
pain.3,60 Additionally, distraction intervention has been shown bleeding, decreased renal blood flow, inhibition of platelet
to lower the perception of pain distress in younger children function, and increased incidence of cardiovascular events.26
as reported by parents.61 Distraction techniques may be of A specific concern with NSAIDs is the potential to exacerbate
great use with patients with special needs that have shortened asthma due to a shift in leukotrienes.76 Due to shared path-
attention spans and are unable to understand verbal reasoning ways, NSAIDs and steroidal anti-inflammatory medications
or reassurance.63 should not routinely be co-administered.81
Imagery guides the child’s attention away from the proce-
dure by harnessing imagination and story-telling. Imagery in Acetaminophen (acetyl-para-aminophenol [APAP], paracetamol).
combination with distraction have been shown to be helpful Acetaminophen is an analgesic with efficacy for mild to
in decreasing postoperative pain in children.67,68 This technique moderate pain and is an antipyretic.81 Unlike NSAIDs,
requires the active cooperation of the patient and is most acetaminophen is centrally-acting and does not have effects
effective when used for children over eight years old.57 on gastric mucosal lining or platelets.81 Its mechanism of
action is the blockade of prostaglandin and substance P pro-
Hypnosis duction. Acetaminophen is administered in tablets, capsules,
Hypnotherapy aims to alter sensory experiences and dissociate and liquid but also is available as oral disintegrating tablets,
from pain experiences, and hypnosis is best for school-aged oral disintegrating films, and rectal and IV forms.50 Studies
or older children.26 There is strong evidence that hypnosis is have shown that rectal administration has somewhat higher
effective in reducing needle-related pain and distress in children bioavailability and faster onset than the oral route since it

partially bypasses hepatic metabolism.80 Pain control can be and/or adenoidectomy pain management, general pain, sore or
optimized when acetaminophen and NSAIDs are alternated strep throat pain, and cold and cough.88 The FDA warns that
or staggered, a technique known as multimodal therapy.76,81,82 in the 12-17-year age group, these medications should not be
used in high-risk patients (e.g., those with obesity, obstructive
Opioid analgesics sleep apnea, lung tissue disease).88 Furthermore, tramadol and
Opioid analgesics have been used for many years to produce codeine should not be used if breastfeeding since active
profound pain relief in all age groups. Opioid analgesics are metabolites are present in breastmilk.88
considered for acute moderate to severe pain refractory to
other therapies. Common uses in pediatric patients include Opioids without active metabolites. Inactive metabolites refer
pain associated with cancer, sickle cell disease, osteogenesis im- to metabolites that do not have a noticeable effect on the CNS.
perfecta, epidermolysis bullosa, and neuromuscular disease.83,84,85 Naturally-occurring morphine and the synthetics oxycodone
Limited studies are available regarding postoperative opioid and fentanyl do not have CYP2D6 considerations since they
use in pediatric dentistry, but it is also rare that pediatric do not contain active metabolites.81 Potency of all opioids
dental patients should require opioid analgesics following is compared to morphine. Morphine provides rapid relief
dental treatment.50 Major concerns of opioid analgesics in the of severe pain for 2-3 hours and is associated with histamine
pediatric population are efficacy, safety, misuse, and accidental release and respiratory depression. Fentanyl is 100 times more
deaths.77,86,87 potent than morphine, ultra-short acting, and used for invasive
Opioids interact differentially with μ, g, and b receptors in procedures and sedations.26 Chest wall rigidity is a well-known
the central nervous system. Opioid agonists act on receptors adverse reaction to fentanyl.26 Rapidly-acting oxycodone has a
located in the brain, spinal cord, and digestive tract. Pathways longer half-life than morphine and is more potent. Oxycodone
of opioid receptor signaling are multiple and include G- is available as a single agent or is combined with aspirin,
protein receptor coupling, cyclic adenosine monophosphate ibuprofen, or acetaminophen. It comes in tablets, capsules, oral
inhibition, and calcium channel inhibition.50 Activation of solution, and oral concentrate, and use is considered off label
opioid receptors can cause respiratory depression, pupil con- in children 12 years of age and younger.50
striction (miosis), euphoria, sedation, physical dependence,
endocrine disruption, and suppression of opiate withdrawal.26 Opioid concerns and Centers for Disease Control and
Pruritus (itching) may also occur due to histamine release that Prevention (CDC) recommendations. Trends in opioid
accompanies some opioid analgesics.48 Naloxone is a μ opioid overdose, opioid misuse, and concerns for opioid addiction
receptor competitive antagonist usually administered parenter- prompted the CDC to issue guidelines for prescribing opioids
ally to counter opioid overdose.50 If patients are actively pre- for chronic pain.30 The guideline aims to improve prescribing
scribed opioids for cancer or non-cancer pain, providers practices to ultimately benefit patient health and quality of
should choose another agent for analgesia or consult with a life.93 Although the guidance is specific for adults with chronic
specialty provider (e.g., pain medicine practitioner, anesthesi- pain, all prescribers should be mindful of high-risk prescrib-
ologist) regarding opioid dosing.77 ing practices.83 The guideline recommends limiting opioids
for moderate to severe pain, restricting prescription to three
Opioids with active metabolites. Codeine, tramadol, and days, and providing concurrent pharmacologic and non-
hydrocodone are opioids that are broken down in the liver pharmacologic therapy.30 The guideline also advises against
to active metabolites by highly variable cytochrome enzyme overlapping benzodiazepines and opioids prescriptions because
CYP2D6.22,81,88 These drugs are ineffective in some children of the increased potential for respiratory depression.30 Dentists
due to poor drug metabolism.9 Yet other patients known as can have a role in decreasing the overall availability of opioids
hyper-metabolizers break these prodrugs to their active forms for nonmedical use and abuse in the home and community.95
too quickly, potentially resulting in overdose, respiratory de- Deaths due to opioid overdoses are at record highs prompt-
pression, and even death.88 The U.S. Food and Drug Admin- ing the CDC to declare an opioid epidemic in 2011.87,95
istration (FDA) and European Medicines Agency have issued Poisoning deaths of opioids nearly quadrupled from 1999 to
warnings and contraindications statements on codeine and 2011, with the most recent data at 5.4 per 100,000 individ-
tramadol over the past few years because of this.88,89 Hydro- uals.95 A trend towards increased pediatric emergency depart-
codone also relies on cytochrome p450 metabolism and has ment visits due to opioid ingestion and a greater than 5-fold
potential for similar adverse effects. Although systematic reviews increase in overdose death rates in the 15-24-year age group
have demonstrated that these medications might provide also have been demonstrated.95 Since commercial opioids often
appropriate analgesia when compared to placebo, evidence is are combined with acetaminophen, the potential for hepatic
not convincing and safety concerns exist.90,91 In 2017, the failure from toxic levels of acetaminophen also must be
FDA issued a warning specifically for codeine and tramadol considered.7 As previously stated, providers treating pediatric
in all patients less than 12 years of age, stating they are no and adolescent populations should avoid prescribing opioid
longer considered safe to use in this age group.88 Deaths have analgesics when patients are using benzodiazepines.30
occurred in children using these medicines for post tonsillectomy

Risky use of opioids among children and adolescents is 6. APAP/NSAIDs should be used as first line pharmacologic
a growing trend, and the concern for opioid use disorder in therapy for pain management.
adolescents is significant.96,97 In 2016, the American Academy 7. Use of opioids should be rare for pain management for
of Pediatrics released a policy statement that recommended pediatric dental patients.
timely intervention to curb opioid use disorder with the goal 8. To help minimize the risk of opioid abuse, pediatric
of eliminating long-term medical, psychiatric, and social con- patients and their parents should be screened regarding
sequences of ongoing substance abuse.98 previous/current opioid use before prescribing opioid
Risk mitigation begins with understanding how to recog- analgesics.
nize drug seeking behavior.2 To address the potential risk 9. To avoid diversion of controlled substances, practitioners
of opioid use/abuse, screening patients prior to prescribing should utilize prescription monitoring databases and
opioids should be standard practice.30 Screening commonly is encourage patients to properly discard any unused
performed with adult patients using a variety of screening medications.
tools.99 Although screening adolescents for opioid abuse or 10. Providers should be knowledgeable of risks associated
misuse has been suggested, a standardized assessment has not with prescribed analgesic medications and anticipate
been identified.77,99 Therefore, the practitioner should, at a and manage adverse effects (e.g., asthma and NSAIDs,
minimum, perform a thorough review of medical history sedation and opioids.)
including analgesics used in the past before prescribing.77 11. Seeking expert consultation for patients with chronic
Despite the fact that screening of parents is recommended pain or other complicated pain condition should be
by the AAP, this is not a common practice.100,101 Nonetheless, considered.
screening is essential for identifying children at risk of opioid 12. Providers should be familiar with analgesic properties
exposure in the home. It also is known that children of parents of agents used during sedation or general anesthesia.
who abuse opioids are at an increased risk for neglect and 13. Prescribing opioid analgesics should be avoided if the
often suffer from parental instability and lack of structure in patient is using benzodiazepines.
the home.101 Therefore, behavioral health support may be 14. Synergistic effect from multiple medications (multimodal
required for emotional disturbances such as drug abuse, analgesia) may be considered.
depression, or post-traumatic stress disorder.101
For professionals who suspect patients have use/abuse References
issues, the FDA, National Institutes of Health, National Insti- 1. International Association for the Study of Pain. Termi-
tute on Drug Abuse, the American Dental Association, and nology. Available at: “https://www.iasp-pain.org/
state prescription drug monitoring programs have resources Education/Content.aspx?ItemNumber=1698#Pain”.
available to review the history of prescriptions for controlled
substances which may decrease their diversion.104 Transparent
Accessed November 24, 2017. (Archived by WebCite
at: “http://www.webcitation.org/6vDlQh5Vw”)
®
discussion of medication use with teens is important.105 Fur- 2. Shaefer J, Barreveld AM, Arnstein P, Kulich RJ. Inter-
thermore, discussion regarding the proper disposal of unused professional education for the dentist in managing acute
controlled medications is key to reducing availability/diversion and chronic pain. Dent Clin North Am 2016;60(4):
of substances with the potential for abuse or for physical 825-42.
and/or psychological dependence. 3. American Academy of Pediatrics, American Pain Society.
The assessment and management of acute pain in
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BEST PRACTICES: RESTORATIVE DENTISTRY
Pediatric Restorative Dentistry

Latest Revision How to Cite: American Academy of Pediatric Dentistry. Pediatric
2019 restorative dentistry. The Reference Manual of Pediatric Dentistry.
Purpose When to restore

The American Academy of Pediatric Dentistry (AAPD) Historically, the management of dental caries was based on
intends these recommendations to help practitioners make the belief that caries was a progressive disease that eventually
decisions regarding restorative dentistry, including when it is destroyed the tooth unless there was surgical and restorative
necessary to treat and what the appropriate materials and intervention.5 It is now recognized that restorative treatment
techniques are for restorative dentistry in children and of dental caries alone does not stop the disease process,6 and
adolescents. restorations have a finite lifespan. Conversely, some caries
lesions may not progress and, therefore, may not need restora-
Methods tion. Contemporary management of dental caries includes
These recommendations originally were developed by the identification of an individual’s risk for caries progression,
Restorative Dentistry Subcommittee of the Clinical Affairs understanding of the disease process for that individual, and
Committee and adopted in 1991. 1 The last comprehensive active surveillance to assess disease progression and manage
revision by the Council of Clinical Affairs of this document with appropriate preventive services, supplemented by restora-
was in 2014,2 and an addition regarding the Hall technique tive therapy when indicated.7,8
(HT) for preformed metal crowns was added in 2016. 3 A With the exception of reports of dental examiners in clini-
thorough review of the scientific literature in the English cal trials, studies of reliability and reproducibility of detecting
language pertaining to restorative dentistry in primary and dental caries are not conclusive. 9 There also is minimal
permanent teeth was completed to revise the previous guide- information regarding validity of caries diagnosis in primary
line. Electronic database and hand searches, for the most part teeth,5 as primary teeth may require different criteria due to
between the years 2000-2019, were conducted using the terms: thinner enamel and dentin and broader proximal contacts.10
dental caries, intra-coronal restorations, restorative treatment Furthermore, indications for restorative therapy only have
decisions, caries diagnosis, caries excavation, dental amalgam, been examined superficially because such decisions generally
glass ionomers, resin modified glass ionomers, conventional have been regarded as a function of clinical judgment.11 Deci-
glass ionomers, atraumatic/alternative restorative technique sions for when to restore caries lesions should include at least
(ART), interim therapeutic restoration (ITR), resin infiltra- clinical criteria of visual detection of enamel cavitations, visual
tions, resin based composite, dental composites, compomers, identification of shadowing of the enamel, and/or radiographic
full coverage dental restorations, stainless steel crowns (SSC), recognition of enlargement of lesions over time.7,12,13
Hall technique, primary molars, preformed metal crowns, strip The benefits of restorative therapy include: removing cavita-
crowns, pre-veneered crowns, zirconia crowns, esthetic tions or defects to eliminate areas that are susceptible to caries;
restorations; parameters: clinical trials, randomized controlled stopping the progression of tooth demineralization; restoring
clinical trials (RCTs). the integrity of tooth structure; preventing the spread of
Full evaluation and abstraction included examination of the infection into the dental pulp; and preventing the shifting of
clinical efficacy on specific restorative dentistry topics, research teeth due to loss of tooth structure. The risks of restorative
methods, and potential for study bias (e.g., patient recruit- therapy include reducing the longevity of teeth by making
ment, randomization, blinding, subject loss, sample size them more susceptible to fracture, recurrent lesions, restoration
estimates, conflicts of interest, statistics). Research that was failure, pulp exposure during caries excavation, future pulpal
considered deficient or had high bias was eliminated. In those complications, and iatrogenic damage to adjacent teeth.14,15
topic areas for which there were rigorous meta-analyses or
systematic reviews available, only those clinical trial articles
that were not covered by the reviews were subjected to full ABBREVIATIONS
evaluation and abstraction. AAPD: American Academy of Pediatric Dentistry. ART: Alternative
The assessment of evidence for each topic was based on a restorative technique. BPA: Bisphenol A. FDA: Food and Drug
modification of the American Dental Association’s grading of Administration. GIC: Glass ionomer cement. HT: Hall technique. ITR:
Interim therapeutic restoration. RCTs: Randomized controlled trials.
recommendations: strong evidence (based on well-executed
RMGIC: Resin modified glass ionomer cements. SSC: Stainless steel
RCTs, meta-analyses, or systematic reviews); evidence in favor crowns. UK: United Kingdom.
(based on weaker evidence from clinical trials).4

Primary teeth may be more susceptible to restoration failures partial (one-step) to stepwise excavation in permanent molars
than permanent teeth.16 Additionally, before restoration of found higher rates of success in maintaining pulp vitality
primary teeth, one needs to consider the length of time re- with partial excavation, suggesting there is no need to reopen
maining prior to tooth exfoliation. the cavity and perform a second excavation. 20 Interestingly,
Recommendations: two RCTs suggest that restoration without excavation can
1. Management of dental caries includes identification of arrest dental caries so long as a good seal of the final restoration
an individual’s risk for caries progression, understanding is maintained.22,29
of the disease process for that individual, and active Recommendations:
surveillance to assess disease progression and manage 1. There is evidence from RCTs and systematic reviews
with appropriate preventive services, supplemented by that incomplete caries excavation in primary and per-
restorative therapy when indicated. manent teeth with normal pulps or reversible pulpitis,
2. Decisions for when to restore carious lesions should in- either partial (one-step) or stepwise (two-step) excavation,
clude at least clinical criteria of visual detection of enamel results in fewer pulp exposures and fewer signs and
cavitation, visual identification of shadowing of the enamel, symptoms of pulpal disease than complete excavation.
and/or radiographic recognition of progression of lesions. 2. There is evidence from two systematic reviews that the
rate of restoration failure in permanent teeth is no higher
Deep caries excavation and restoration after incomplete rather than complete caries excavation.
Among the objectives of restorative treatment are to repair or 3. There is evidence that partial (one-step) excavation fol-
limit the damage from caries, protect and preserve the tooth lowed by placement of final restoration leads to higher
structure, and maintain pulp vitality whenever possible. The success in maintaining pulp vitality in permanent teeth
AAPD's Use of Vital Pulp Therapies in Primary Teeth with than stepwise (two-step) excavation.
Deep Caries Lesions 17 and Pulp Therapy for Primary and
Immature Permanent Teeth18 state the treatment objective for Resin infiltration
a tooth affected by caries is to maintain pulpal vitality, Resin infiltration is used primarily to arrest the progression
especially in immature permanent teeth for continued of non-cavitated interproximal caries lesions.30,31 The aim of
apexogenesis.19 the resin infiltration technique is to allow penetration of a low
With regard to the treatment of deep caries, three methods viscosity resin into the porous lesion body of enamel caries.30
of caries removal have been compared to complete excavation, Once polymerized, this resin serves as a barrier to acids and
where all carious dentin is removed. Stepwise excavation is a theoretically prevents lesion progression.32
two-step caries removal process in which carious dentin is A systematic review and meta-analysis evaluated the
partially removed at the first appointment, leaving caries over effectiveness of enamel infiltration in preventing initial caries
the pulp, with placement of a temporary filling. At the second progression in proximal surfaces of primary and permanent
appointment, all remaining carious dentin is removed and a teeth. This review identified eight studies for inclusion for
final restoration placed.19 Partial, or one-step, caries excavation quantitative analysis.33 Seven of the eight studies found that
removes part of the carious dentin, but leaves caries over the infiltration was significantly more effective than placebo treat-
pulp, and subsequently places a base and final restoration.20,21 ment. The meta-analysis compared 470 teeth in the resin
No removal of caries before restoration of primary molars in infiltration group and 473 in the control group. Caries pro-
children aged three to 10 years also has been reported.22 gression was seen in 61 of the infiltration group and 185 of the
Evidence from RCTs and a systematic review shows that control group. Current American Dental Association clinical
pulp exposures in primary and permanent teeth are signifi- practice guidelines for non-restorative treatment for non-
cantly reduced using incomplete caries excavation compared cavitated interproximal caries lesions conditionally recommends
to complete excavation in teeth with a normal pulp or re- enamel infiltration for treatment of these lesions, (low to very
versible pulpitis. Two trials and a Cochrane review found low certainty).34 Few RCTs evaluate the long-term effectiveness
that partial excavation resulted in significantly fewer pulp of resin infiltration, and further research is recommended. An
exposures compared to complete excavation.23-25 Two trials additional use of resin infiltration has been suggested to
of step-wise excavation showed that pulp exposure occurred restore white spot lesions formed during orthodontic treatment.
more frequently from complete excavation compared to Based on a RCT, resin infiltration significantly improved the
stepwise excavation.19,24 There also is evidence of a decrease in clinical appearance of such white spot lesions and visually
pulpal complications and post-operative pain after incomplete reduced their size.35,36
caries excavation compared to complete excavation in clinical Recommendation:
trials, summarized in a meta-analysis.28 1. There is low to moderate evidence in favor of resin infil-
Additionally, a meta-analysis found the risk for permanent tration as a treatment option for small, non-cavitated in-
restoration failure was similar for incompletely and completely terproximal caries lesions in primary and permanent teeth.
excavated teeth.28 With regard to the need to reopen a tooth 2. Further research regarding long-term effectiveness of resin
with partial excavation of caries, one RCT that compared infiltration is needed.

Dental amalgam composite and amalgam are statistically equivalent after ten
Dental amalgam has been the most commonly used restorative years, at 92 percent and 94 percent respectively.42
material in posterior teeth for over 150 years.37 Amalgam con- The limitation of many of the clinical trials that compare
tains a mixture of metals such as silver, copper, and tin, in dental amalgam to other restorative materials is that the study
addition to approximately 50 percent mercury. 38 Dental period often is short (24 to 36 months), at which time interval
amalgam has declined in use over the past decade,37 perhaps all materials reportedly perform similarly.51-55 Some of these
due to the controversy surrounding perceived health effects of studies also may be at risk for bias, due to lack of true ran-
mercury vapor, environmental concerns from its mercury domization, inability of blinding of investigators, and, in some
content, and increased demand for esthetic alternatives. cases, financial support by the manufacturers of the dental
With regard to safety of dental amalgam, a comprehensive materials being studied.
literature review of dental studies published between 2004 Recommendation:
and 2008 found insufficient evidence of associations between There is strong evidence that dental amalgam is efficacious
mercury release from dental amalgam and the various medi- in the restoration of Class I and Class II cavity restorations in
cal complaints. 39 Two independent RCTs in children have primary and permanent teeth.
examined the effects of mercury release from amalgam restora-
tions and found no effect on the central and peripheral nervous Composites
systems and kidney function.40,41 However, on July 28, 2009, Resin-based composite restorations were introduced in dentistry
the U.S. Food and Drug Administration (FDA) issued a final about a half century ago as an esthetic restorative material56,57,
rule that reclassified dental amalgam to a Class II device and composites increasingly are used in place of amalgam for
(having some risk) and designated guidance that included the restoration of carious lesions.58 Composites consist of a
warning labels regarding: (1) possible harm of mercury vapors; resin matrix and chemically bonded fillers.42 They are classified
(2) disclosure of mercury content; and (3) contraindications according to their filler size, because filler size affects
for persons with known mercury sensitivity. Also in this final polishability/esthetics, polymerization depth, polymerization
rule, the FDA noted that there is limited information regarding shrinkage, and physical properties. Hybrid resins combine a
dental amalgam and the long-term health outcomes in mixture of particle sizes for improved strength while retaining
pregnant women, developing fetuses, and children under the esthetics.59 The smaller filler particle size allows greater pol-
age of six.38 ishability and esthetics, while larger size provides strength.
With regard to clinical efficacy of dental amalgam, results Flowable resins have a lower volumetric filler percentage than
comparing longevity of amalgam to other restorative materials hybrid resins.60
are inconsistent. The majority of meta-analyses, evidence-based Several factors contribute to the longevity of resin composites,
reviews, and RCTs report comparable durability of dental including operator experience, restoration size, and tooth po-
amalgam to other restorative materials,42-47 while others show sition.48 Resins are more technique sensitive than amalgams
greater longevity for amalgam.48,49 The comparability appears and require longer placement time. In cases where isolation or
to be especially true when the restorations are placed in patient cooperation is in question, resin-based composite may
controlled environments such as university settings.42 not be the restorative material of choice.61
Class I amalgam restorations in primary teeth have shown Bisphenol A (BPA) and its derivatives are components of
in a systematic review and two RCTs to have a success rate of resin-based dental sealants and composites. Trace amounts of
85 to 96 percent for up to seven years, with an average annual BPA derivatives are released from dental resins through salivary
failure rate of 3.2 percent16,46,49 Efficacy of Class I amalgam enzymatic hydrolysis and may be detectable in saliva up to
restorations in permanent teeth of children has been shown three hours after resin placement.62 Evidence is accumulating
in two independent randomized controlled studies to range that certain BPA derivatives may pose health risks attributable
from 89.8 to 98.8 percent for up to seven years.46,48 to their estrogenic properties. BPA exposure reduction is
With regard to Class II restorations in primary molars, a achieved by cleaning filling surfaces with pumice and cotton
2007 systematic review concluded that amalgam should be roll and rinsing. Additionally, potential exposure can be reduced
expected to survive a minimum of 3.5 years and potentially in by using a rubber dam.62 Considering the proven benefits of
excess of seven years.50 For Class II restorations in permanent resin based dental materials and minimal exposure to BPA and
teeth, one meta-analysis and one evidence-based review conclude its derivatives, it is recommended to continue using these
that the mean annual failure rates of amalgam and composite products while taking precautions to minimize exposure.62
are equal at 2.3 percent.42,45 The meta-analysis comparing There is strong evidence from a meta-analysis of 59
amalgam and composite Class II restorations in permanent RCTs of Class I and II composite and amalgam restorations
teeth suggests that higher replacement rates of composite in showing an overall success rate about 90 percent after 10 years
general practice settings can be attributed partly to general for both materials, with rubber dam use significantly increasing
practitioners’ confusion of marginal staining for marginal caries restoration longevity.42 Other isolation techniques (e.g., dental
and their subsequent premature replacements. Otherwise, isolation suction systems) may be used. Strong evidence from
this meta-analysis concludes that the median success rate of RCTs comparing composite restorations to amalgam restorations

showed that the main reason for restoration failure in both Regarding use of conventional glass ionomers in primary
materials was recurrent caries.46,48,63 teeth, one RCT showed the overall median time from treat-
In primary teeth, there is strong evidence that compos- ment to failure of glass ionomer restored teeth was 1.2 years.49
ite restorations for Class I restorations are successful. 16,46 Based on findings of a systematic review and meta-analysis,
There is only one RCT showing success in Class II composite conventional glass ionomers are not recommended for Class II
restorations in primary teeth that were expected to exfoliate restorations in primary molars.77,78 Conventional glass ionomer
within two years.53 In permanent molars, composite replace- restorations have other drawbacks such as poor anatomical
ment after 3.4 years was no different than amalgam,46 but form and marginal integrity.79,80 Composite restorations were
after seven to 10 years the replacement rate was higher for more successful than GICs where moisture control was not a
composite.61 Secondary caries rate was reported as 3.5 times problem.78
greater for composite versus amalgam.48 There is evidence Resin-modified glass-ionomer cements (RMGICs), with the
from a meta-analysis showing that etching and bonding of acid-base polymerization supplemented by a second resin light
enamel and dentin significantly decreases marginal staining cure polymerization, have been shown to be efficacious in
and detectable margins in composite restorations.42 Regarding primary teeth. Based on a meta-analysis, RMGIC is more
different types of composites (packable, hybrid, nanofilled, successful than conventional glass ionomer as a restorative
macrofilled, and microfilled) there is strong evidence showing material.78 A systematic review supports the use of RMGIC in
similar overall clinical performance for these materials.64-67 small to moderate sized Class II cavities.77 Class II RMGIC
Recommendations: restorations are able to withstand occlusal forces on primary
1. In primary molars, there is strong evidence from RCTs molars for at least one year. 78 Because of fluoride release,
that composite resins are successful when used in Class RMGIC may be considered for Class I and Class II restora-
I restorations. For Class II lesions in primary teeth, tions of primary molars in a high caries risk population. 80
there is one RCT showing success of composite resin There is also some evidence that conditioning dentin
restorations for two years. improves the success rate of RMGIC.77 According to one RCT,
2. In permanent molars, there is strong evidence from meta- cavosurface beveling leads to high marginal failure in
analyses that composite resins can be used successfully RMGIC restorations and is not recommended.63
for Class I and II restorations. With regard to permanent teeth, a meta-analysis review
3. Evidence from a meta-analysis shows enamel and dentin reported significantly fewer carious lesions on single-surface
bonding agents decrease marginal staining and detectable glass ionomer restorations in permanent teeth after six years
margins for the different types of composites. as compared to restorations with amalgam. 80 Data from a
meta-analysis shows that RMGIC is more caries preventive
Glass-ionomer cements (GIC) than composite resin with or without fluoride.81 Another meta-
Glass-ionomers cements have been used in dentistry as restor- analysis showed that cervical restorations (Class V) with glass
ative cements, cavity liner/base, and luting cement since the ionomers may have a good retention rate, but poor esthetics.82
early 1970s.68 Originally, glass ionomer materials were difficult For Class II restorations in permanent teeth, one RCT showed
to handle, exhibited poor wear resistance, and were brittle. unacceptable high failure rates of conventional glass ionomers,
Advancements in conventional glass ionomer formulation led irrespective of cavity size. However, a high dropout rate was
to better properties, including the formation of resin-modified observed in this study limiting its significance.83 In general,
glass ionomers. These products showed improvement in there is insufficient evidence to support the use of RMGIC as
handling characteristics, decreased setting time, increased long-term restorations in permanent teeth.
strength, and improved wear resistance.69,70 All glass ionomers Other applications of glass ionomers where fluoride release
have several properties that make them favorable for use in has advantages are for ITR and ART. These procedures have
children including: chemical bonding to both enamel and similar techniques but different therapeutic goals. ITR may
dentin; thermal expansion similar to that of tooth structure; be used in very young patients, 84 uncooperative patients, or
biocompatibility; uptake and release of fluoride; and decreased patients with special health care needs47 for whom traditional
moisture sensitivity when compared to resins. cavity preparation and/or placement of traditional dental
Fluoride is released from glass ionomer and taken up by the restorations are not feasible or need to be postponed.
surrounding enamel and dentin, resulting in teeth that are less Additionally, ITR may be used for caries control in children
susceptible to acid challenge.71,72 One study has shown that with multiple open carious lesions, prior to definitive
fluoride release can occur for at least one year.73 Glass ionomers restoration of the teeth. 85 In-vitro, leaving caries-affected
can act as a reservoir of fluoride, as uptake can occur from dentin does not jeopardize the bonding of glass ionomer
dentifrices, mouth rinses, and topical fluoride applications.74,75 cements to the primary tooth dentin.86 ART, endorsed by the
This fluoride protection, useful in patients at high risk for World Health Organization and the International Association
caries, has led to the use of glass ionomers as luting cement for Dental Research, is a means of restoring and preventing
for SSCs, space maintainers, and orthodontic bands.76 caries in populations that have little access to traditional dental
care and functions as definitive treatment.

According to a meta-analysis, single surface ART restora- Recommendations:

tions showed high survival rates in both primary and perma- 1. Compomers can be an alternative to other restorative
nent teeth.87 One RCT supported single surface restorations materials in the primary dentition in Class I and Class
irrespective of the cavity size and also reported higher success II restorations.
in non-occlusal posterior ART compared to occlusal posterior 2. There is not enough data comparing compomers to other
ART.88 With regard to multi-surface ART restorations, there is restorative materials in permanent teeth of children.
conflicting evidence. Based on a meta-analysis, ART restorations
presented similar survival rates to conventional approaches Preformed metal crowns
using composite or amalgam for Class II restorations in Preformed metal crowns also known as SSCs are prefabricated
primary teeth.89 However, another meta-analysis showed that crown forms that are adapted to individual teeth and
multi-surface ART restorations in primary teeth exhibited cemented with a biocompatible luting agent. Preformed metal
high failure rates.87 crowns have been indicated for the restoration of primary
Recommendations: and permanent teeth with extensive caries, cervical decalcifi-
1. There is evidence in favor of GICs for Class I restorations cation, and/or developmental defects (e.g., hypoplasia,
in primary teeth. hypocalcification), when failure of other available restorative
2. From a systematic review, there is strong evidence that materials is likely (e.g., interproximal caries extending beyond
RMGICs for Class I restorations are efficacious, and line angles, patients with bruxism), following pulpotomy or
expert opinion supports Class II restorations in primary pulpectomy, for restoring a primary tooth that is to be used
teeth. as an abutment for a space maintainer, for the intermediate
3. There is insufficient evidence to support the use of restoration of fractured teeth, and for definitive restorative
conventional or RMGICs as long-term restorative material treatment for high caries-risk children. They are used more
in permanent teeth. frequently in patients whose treatment is performed under
4. From a meta-analysis, there is strong evidence that sedation or general anesthesia.97-99
ITR/ART using high viscosity glass ionomer cements There are very few prospective RCTs comparing outcomes
has value as single surface temporary restoration for for preformed metal crowns to intra-coronal restorations.100,101
both primary and permanent teeth. Additionally, ITR A Cochrane review and two systematic reviews conclude that
may be used for caries control in children with multiple the majority of clinical evidence for the use of preformed
open carious lesions, prior to definitive restoration of metal crowns has come from nonrandomized and retrospective
the teeth. studies.16,97-99 However, this evidence suggests that preformed
metal crowns showed greater longevity than amalgam restora-
Compomers tions,16 despite possible study bias of placing SSCs on teeth
Polyacid-modified resin-based composites, or compomers, more damaged by caries.98,99,102 Five studies which retrospec-
were introduced into dentistry in the mid-1990s. They contain tively compared Class II amalgam to preformed metal crowns
72 percent (by weight) strontium fluorosilicate glass and the showed an average five year failure rate of 26 percent for
average particle size is 2.5 micrometers.90 Moisture is attracted amalgam and seven percent for preformed metal crowns.98
to both acid functional monomer and basic ionomer-type in A two-year RCT regarding restoration of primary teeth
the material. This moisture can trigger a reaction that releases that had undergone a pulpotomy procedure found a non-
fluoride and buffers acidic environments.91,92 Considering the significant difference in survival rate for teeth restored with
ability to release fluoride, esthetic value, and simple handling preformed metal crowns (95 percent) versus resin modified
properties of compomer, it can be useful in pediatric dentistry.90 glass ionomer/composite restoration (92.5 percent).100 In
Based on a recent RCT, the longevity of Class I compomer another prospective study, significantly fewer restoration failures
restorations in primary teeth was not statistically different and improved calcium hydroxide pulpotomy success were
compared to amalgam, but compomers were found to need found with preformed metal crowns (79.7 percent) versus
replacement more frequently due to recurrent caries.46 In amalgam restorations (60 percent) after one year.103 However, a
Class II compomer restorations in primary teeth, the risk of systematic review did not show strong evidence that preformed
developing secondary caries and failure did not increase over metal crowns were superior over other restorations for pulpo-
a two-year period in primary molars.54,93 Compomers also tomized teeth.104
have reported comparable clinical performance to composite With regards to gingival health adjacent to preformed
with respect to color matching, cavo-surface discoloration, metal crowns, a one year RCT showed no difference in
anatomical form, and marginal integrity and secondary gingival inflammation between preformed metal crowns and
caries.94,95 Most RCTs showed that compomer tends to have composite restorations after pulpotomy. 99 Yet, a two-year
better physical properties compared to glass ionomer and resin randomized clinical study showed more gingival bleeding
modified glass ionomer cements and in primary teeth, but for preformed metal crowns vs. composite/glass ionomer
no significant difference was found in cariostatic effects of restorations.100 Inadequately contoured crown and residues of
compomer compared to these materials.49,93,96 set cement remaining in contact with the gingival sulcus are

suggested as reasons for gingivitis associated with preformed Recent retrospective studies118,119 for cost-effectiveness com-
metal crowns, and a preventive regime including oral hygiene bined with a cross-sectional evaluation of patient acceptance
instruction is recommended to be incorporated into the showed that 95.8 percent of primary teeth restored using the
treatment plan.98 HT remained asymptomatic after a follow-up period of up
There is one RCT on preformed metal crowns versus cast to 77 months, compared to 95.3 percent in the conventional
crowns placed on permanent teeth,105 and this report found methods (caries removal with placement of SSC or other
no difference between the two restoration types for quality restoration); they did not, however, report a breakdown by
and longevity after 24 months. The remaining evidence is follow-up time. Although HT and conventional restorative
case reports and expert opinion concerning indications for methods had similar successful outcomes, using the HT was
use of preformed metal crowns on permanent molars. The associated with reduced treatment costs if general anesthesia
indications include teeth with severe genetic/developmental or sedation is considered. Both approaches were accepted
defects, grossly carious teeth, and traumatized teeth, along with favorably by the children and care providers.119
tooth developmental stage or financial considerations that re- SSCs continue to offer the advantage of full coverage to
quire semi-permanent restoration instead of a permanent cast combat recurrent caries and provide strength as well as long-
restoration. 97,102,105 The main reasons for preformed metal term durability with minimal maintenance, which are desirable
crown failure reportedly are crown loss16,103,106 and perforation106. outcomes for caries management for high-risk children.
One method of providing preformed metal crowns is The interest in esthetic options for full coverage restoration
known as HT.107 This method calls for cementation of a SSC of primary posterior teeth is increasing by clinicians and pa-
over a caries-affected primary molar without local anesthetic, tients.120,121 Scientific studies that evaluate esthetic options for
caries removal, or tooth preparation. It is a less invasive caries restoring teeth with large caries lesions are not widely reported
management procedure for treating carious primary teeth and in the literature. The most popular options are opened-face
involves the concept of caries control by managing the SSCs, pre-veneered SSCs, and zirconia crowns.122 There are
activity of the biofilm.108 This technique was developed for several preformed pediatric zirconia crowns available on the
use when delivery of ideal treatment was not feasible. Using market, and each brand has different material composition,
the HT may reduce discomfort from local anesthetic and fabrication, surface treatment, retentive feature, and cementa-
caries removal at the time of treatment compared to fillings,107 tion method. The amount of tooth reduction and technique
but it may add the discomfort of placement of separator bands for tooth preparation varies significantly. 123 There is need
prior to the SSC, as well as the pain from biting the crown for more circumferential tooth reduction requirements for
into place. 109 The HT has gained some popularity in the proper fit and placement for zirconia crowns compared to
United Kingdom (UK),107 primarily from use by general dentists SSCs. The indications for the preformed esthetic crowns are
(who provide the majority of care for young children).110 generally the same as those of the preformed SSCs but with
All prospective investigations on the effectiveness of HT have consideration of esthetics.124 SSCs have comparatively better
been by general dentists in UK, and comparison groups include retention, but recent studies demonstrate that the gingival
restorative treatment as traditionally provided in those settings, health and plaque accumulation around zirconia crowns are
where traditional use of SSCs to restore caries in primary teeth better than SSCs.124,125
has not been a popular or a frequently used technique.111-114 Recommendations:
This is in spite of the existence of guidelines and policy 1. There is evidence from retrospective studies showing
statements from the British Society of Paediatric Dentistry that greater longevity of preformed metal crown restorations
SSCs are the restoration of choice for primary molars with compared to amalgam or resin-based restorations for the
multi-surface lesions or extensive caries or when pulp treatment treatment of caries lesions in primary teeth. Therefore,
has been performed.115,116 use of SSCs is supported on high-risk children with
Results of a 2003 repeat questionnaire of general dentists large or multi-surface cavitated or non-cavitated lesions
in the UK showed that the use of amalgam had declined with on primary molars, especially when children require
an increase in the use of GIC and very little change in the advanced behavioral guidance techniques126 including
use of SSCs.111 Placement of GIC restorations or observation general anesthesia for the provision of restorative dental
without treatment was the management approach of choice, care.
and the use of local anesthesia to provide dental care to 2. There is evidence from case reports and one RCT sup-
children was infrequent.112 Given the differences in treatment porting the use of preformed metal crowns in permanent
approaches in health care settings and system between teeth as a semi-permanent restoration for the treatment
countries, the HT has not been widely adopted in the U.S., of severe enamel defects or grossly carious teeth.
and it usually is limited to individual situations where proven
methods of caries management cannot be used. 117 Studies Anterior esthetic restorations in primary teeth
that compare this technique to traditionally placed preformed Despite the continuing prevalence of dental caries in primary
metal crowns using radiographic assessment and caries removal maxillary anterior teeth in children, the esthetic management
are needed.117 of these teeth remains problematic.127 Esthetic restoration of

primary anterior teeth can be especially challenging due to: large surface area for bonding to enhance retention.129 Resin-
the small size of the teeth; close proximity of the pulp to the based restorations are appropriate for anterior teeth that can
tooth surface; relatively thin enamel; lack of surface area for be adequately isolated from saliva and blood. Resin-modified
bonding; and issues related to child behavior.128 glass ionomer cements have been suggested for this catego-
There is little scientific support for any of the clinical tech- ry, especially when adequate isolation is not possible.130,131 It
niques that clinicians have utilized for many years to restore has been suggested that patients considered at high-risk for
primary anterior teeth, and most of the evidence is regarded as future caries may be better served with placement of full
expert opinion. While a lack of strong clinical data does not tooth coverage restorations.131
preclude the use of these techniques, it points out the strong Class V (cervical) cavity preparations for primary incisors
need for well designed, prospective clinical studies to validate are similar to those in permanent teeth. Due to the young
the use of these techniques.129 Additionally, there is limited age of children treated and associated behavior guidance
information on the potential psychosocial impact of anterior difficulty, it is sometimes impossible to isolate teeth for the
caries or unaesthetic restorations in primary teeth.127 placement of composite restorations. In these cases, GIC or
Class III (interproximal) restorations of primary incisors RMGIC is suggested.130,131
can be prepared with labial or lingual dovetails to incorporate a
Table 1. EVIDENCE OF EFFICACY OF VARIOUS DENTAL MATERIALS/TECHNIQUES IN PRIMARY TEETH WITH REGARD TO
CARIES LESION CLASSIFICATIONS
Strong evidence – based on well executed randomized control trials, meta-analyses, or systematic reviews; Evidence in favor – based on
weaker evidence from clinical trials; Expert opinion – based on retrospective trials, case reports, in vitro studies and opinions from clinical
researchers; Evidence against – based on randomized control trials, meta-analysis, systematic reviews.
Class I Class II Class III Class IV Class V

Amalgam Strong evidence Strong evidence No data No data Expert opinion
Composite Strong evidence Strong evidence Expert opinion No data Evidence in favor
Glass ionomer Strong evidence _ Evidence against ` Evidence in favor a No data Expert opinion a
RMGIC Strong evidence Expert opinion b Expert opinion No data Expert opinion
Compomers Evidence in favor Evidence in favor No data No data Expert opinion
SSC Evidence in favor ¡ Evidence in favor ¡ No data No data No data
Anterior q N/A N/A Expert opinion Expert opinion Expert opinion
crowns
RMGIC = resin modified glass ionomer cement. SSC = stainless steel crown.
_ Evidence from ART trials. b Small restorations; life span 1-2 years.
` Conflicting evidence for multisurface ART restorations. ¡ Large lesions.
a Preference when moisture control is an issue. q Strip crowns, stainless steel crowns with/without facings, zirconia crowns.
Table 2. EVIDENCE OF EFFICACY OF VARIOUS DENTAL MATERIALS/TECHNIQUES IN PERMANENT TEETH WITH REGARD
TO CARIES LESION CLASSIFICATIONS
Class I Class II Class III Class IV Class V
Amalgam Strong evidence Strong evidence No data No data No data
Composite Strong evidence Evidence in favor Expert opinion No data Evidence in favor
Glass ionomer Strong evidence _ Evidence against Evidence in favor ` No data Expert opinion `
RMGIC Strong evidence No data Expert opinion No data Evidence in favor
Compomers Evidence in favor a No data Expert opinion No data Expert opinion
SSC Evidence in favor b Evidence in favor b No data No data No data
Anterior q N/A N/A No data No data No data
crowns
RMGIC = resin modified glass ionomer cement. SSC = stainless steel crown.
_ Evidence from ART trials. a Evidence from studies in adults.
` Preference when moisture control is an issue. b For children and adolescents with gross caries or severely hypoplastic teeth.
q Strip crowns, stainless steel crowns with/without facings.

Full coronal restoration of carious primary incisors may be References

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BEST PRACTICES: PULP THERAPY
Pulp Therapy for Primary and Immature

Permanent Teeth
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Pulp therapy
2020 for primary and immature permanent teeth. The Reference Manual
Dentistry; 2020:384-92.
Purpose as: normal pulp (symptom free and normally responsive to

The American Academy of Pediatric Dentistry (AAPD) intends vitality testing), reversible pulpitis (pulp is capable of healing),
these recommendations to aid in the diagnosis of pulp health symptomatic or asymptomatic irreversible pulpitis (vital
versus pathosis and to set forth the indications, objectives, inflamed pulp is incapable of healing), or necrotic pulp. 3 The
and therapeutic interventions for pulp therapy in primary and clinical diagnosis derived from:4-7
immature permanent teeth. 1. a comprehensive medical history.
2. a review of past and present dental history and
Methods treatment, including current symptoms and chief
Recommendations on pulp therapy for primary and immature complaint.
permanent teeth were developed by the Clinical Affairs 3. a subjective evaluation of the area associated with the
Committee – Pulp Therapy Subcommittee and adopted in current symptoms/chief complaint by questioning
1991.1 This document by the Council of Clinical Affairs is the patient/parent on the location, intensity,
a revision of the previous version, last revised in 2014.2 This duration, stimulus, relief, and spontaneity.
revision included a new search of the PubMed /
MEDLINE database using the terms: pulpotomy, pulpectomy,
® 4. an objective extraoral examination as well as examina-
tion of the intraoral soft and hard tissues.
pulpectomy primary teeth, indirect pulp treatment (IPT), 5. if obtainable, radiograph(s) to diagnose periapical or
stepwise excavation, pulp therapy, pulp capping, pulp periradicular changes.
exposure, bases, liners, calcium hydroxide, formocresol, ferric 6. clinical tests such as palpation, percussion, and
sulfate, glass ionomer, mineral trioxide aggregate (MTA), mobility; however, electric pulp and thermal tests are
bacterial microleakage under restorations, lesion sterilization unreliable in immature permanent and primary teeth.
tissue repair (LSTR), dentin bonding agents, resin modified
glass ionomers, and endodontic irrigants; fields: all. Papers Teeth exhibiting provoked pain of short duration relieved
for review were chosen from the resultant lists and from with over-the-counter analgesics, by brushing, or upon the
hand searches. When data did not appear sufficient or were removal of the stimulus and without signs or symptoms of
inconclusive, recommendations were based upon expert and/ irreversible pulpitis have a clinical diagnosis of reversible pulp-
or consensus opinion including those from the 2007 joint itis and are candidates for vital pulp therapy. Teeth diagnosed
symposium of the AAPD and the American Association of with a normal pulp requiring pulp therapy or with reversible
Endodontists (AAE) titled Emerging Science in Pulp Therapy: pulpitis should be treated with vital pulp therapy.8-11
New Insights into Dilemmas and Controversies (Chicago, Ill.) Teeth exhibiting signs or symptoms such as a history of
spontaneous unprovoked pain, a sinus tract, soft tissue inflam-
Background mation not resulting from gingivitis or periodontitis, excessive
The primary goal of pulp therapy is to maintain the integrity mobility not associated with trauma or exfoliation, furcation/
and health of the teeth and their supporting tissues while apical radiolucency, or radiographic evidence of internal/
maintaining the vitality of the pulp of a tooth affected by external resorption have a clinical diagnosis of irreversible pulp-
caries, traumatic injury, or other causes. Especially in young itis or necrosis and are candidates for nonvital pulp treatment.12
permanent teeth with immature roots, the pulp is integral to
continue apexogenesis. Long term retention of a permanent
tooth requires a root with a favorable crown/root ratio and ABBREVIATIONS
dentinal walls that are thick enough to withstand normal AAE: American Association of Endodontists. AAPD: American
function. Therefore, pulp preservation is a primary goal for Academy of Pediatric Dentistry. DPC: Direct pulp cap. IPT: Indirect
treatment of the young permanent dentition. pulp therapy. ITR: Interim therapeutic restoration. LSTR: Lesion
sterilization/tissue repair. MTA: Minera ltrioxide aggregate. ZOE:
The indications, objectives, and type of pulpal therapy are Zinc oxide eugenol.
based on the health status of the pulp tissue which is classified

Regenerative endodontics may be considered for immature Primary teeth

permanent teeth with apical periodontitis, a necrotic pulp, and Vital pulp therapy for primary teeth diagnosed with a normal
immature apex.13 pulp or reversible pulpitis
Protective liner. A protective liner is a thinly-applied material
Recommendations placed on the dentin in proximity to the underlying pulpal
All relevant diagnostic information, treatment, and treatment surface of a deep cavity preparation, covering exposed dentin
follow-up shall be documented in the patient’s record. tubules to act as a protective barrier between the restorative
Any planned treatment should include consideration of: material or cement and the pulp. Placement of a thin protective
1. the patient’s medical history; liner such as MTA, trisilicate cements, calcium hydroxide, or other
2. the value of each involved tooth in relation to the biocompatible material is at the discretion of the clinician.19,20
child’s overall development; • Indications: In a tooth with a normal pulp when all caries
3. alternatives to pulp treatment; and is removed for a restoration, a protective liner may be placed
4. restorability of the tooth. in the deep areas of the preparation to minimize injury to
the pulp, promote pulp tissue healing, and/or minimize
When the infectious process cannot be arrested by the post-operative sensitivity.21,22
treatment methods included in this section, bony support • Objectives: The placement of a liner in a deep area of the
cannot be regained, inadequate tooth structure remains for preparation is utilized to preserve the tooth’s vitality, pro-
a restoration, or excessive pathologic root resorption exists, mote pulp tissue healing and tertiary dentin formation, and
extraction should be considered.4,12 minimize bacterial microleakage.23 Adverse post-treatment
This document is intended to recommend the best available clinical signs or symptoms such as sensitivity, pain, or
clinical care for pulp treatment, but the AAPD encourages swelling should not occur.
additional research for consistently successful and predictable
techniques using biologically-compatible medicaments for Indirect pulp treatment. IPT is a procedure performed in a
vital and non-vital primary and immature permanent teeth. tooth with a deep caries lesion approximating the pulp but
Pulp therapy requires periodic clinical and radiographic assess- without evidence of radicular pathology. “Indirect pulp treat-
ment of the treated tooth and the supporting structures.14 ment is a procedure that leaves the deepest caries adjacent to
Post-operative clinical assessment generally should be performed the pulp undisturbed in an effort to avoid a pulp exposure.
every six months and could occur as part of a patient’s periodic This caries-affected dentin is covered with a biocompatible
comprehensive oral examination. Patients treated for an acute material to produce a biological seal.”17 A radiopaque liner such
dental infection initially may require more frequent clinical as a dentin bonding agent,24,25 resin modified glass ionomer,4
reevaluation. A radiograph of a primary tooth pulpectomy calcium hydroxide,25 or MTA (or any other biocompatible
should be obtained immediately following the procedure.5 This material)26 is placed over the remaining carious dentin to
can document the quality of the fill and help determine the stimulate healing and repair. The liner that is placed over the
tooth’s prognosis. This image also would serve as a comparative dentin (calcium hydroxide, glass ionomer, or bonding agents)
baseline for future films (the type and frequency of which are does not affect the IPT success.27 The tooth then is restored
at the clinician’s discretion). Radiographic evaluation of primary with a material that seals the tooth from microleakage.
tooth pulpotomies should occur at least annually because the Interim therapeutic restorations (ITR) with glass ionomer
success rate of pulpotomies diminishes over time.15 Bitewing cements may be used for caries control in teeth with carious
radiographs obtained as part of the patient’s periodic compre- lesions that exhibit signs of reversible pulpitis. The ITR can
hensive examinations may suffice. If a bitewing radiograph be removed once the pulp’s vitality is determined and, if the
does not display the interradicular area, a periapical image is pulp is vital, an indirect pulp cap can be performed.15,28 Current
indicated. Immature permanent teeth treated with pulp therapy literature indicates that there is no conclusive evidence that it
also should have close clinical and radiographic follow-up to is necessary to reenter the tooth to remove the residual caries.29,30
confirm that pulpal pathology is not developing.16 Isolation is As long as the tooth remains sealed from bacterial contami-
necessary to minimize bacterial contamination and to protect nation, the prognosis is good for caries to arrest and reparative
soft and hard tissues. Use of rubber dam isolation is considered dentin to form to protect the pulp.29-34 Indirect pulp treatment
a gold standard17 for pulpal treatment. When unable to use a has been shown to have a higher success rate than direct pulp
rubber dam, other effective isolation may be considered. cap (DPC) and pulpotomy in long term studies.8,10,15,25,27,35-40
When a pulp exposure occurs and pulp therapy is indicated, IPT also allows for a normal exfoliation time. Therefore, IPT
irrigants for pulpal therapy should not come from dental unit can be chosen instead of DPC or pulpotomy when the pulp is
water lines. The CDC states “conventional dental units cannot normal or has a diagnosis of reversible pulpitis and there
reliably deliver sterile water even when equipped with inde- is no pulpal exposure.
pendent water reservoirs containing sterile water because the • Indications: IPT is indicated in a primary tooth with deep
water-bearing pathway cannot be reliably sterilized.”18 A single caries that exhibits no pulpitis or with reversible pulpitis
use disposable syringe should be used to dispense irrigants for when the deepest carious dentin is not removed to avoid a
pulpal therapy.

pulp exposure.9,27 The pulp is judged by clinical and radio- pulp exposure,7 and when there are no radiographic signs of
graphic criteria to be vital and able to heal from the carious infection or pathologic resorption. When the coronal tissue
insult.17,27 is amputated, the remaining radicular tissue must be judged
• Objectives: The restorative material should seal completely to be vital without suppuration, purulence, necrosis, or
the involved dentin from the oral environment. The tooth’s excessive hemorrhage that cannot be controlled by a cotton
vitality should be preserved. No post-treatment signs or pellet after several minutes.4
symptoms such as sensitivity, pain, or swelling should be • Objectives: The radicular pulp should remain asymptom-
evident. There should be no radiographic evidence of patho- atic without adverse clinical signs or symptoms such as sensi-
logic external or internal root resorption or other pathologic tivity, pain, or swelling. There should be no postoperative
changes. There should be no harm to the succedaneous radiographic evidence of pathologic external root resorption.
tooth. Internal root resorption may be self-limiting and stable. The
clinician should monitor the internal resorption, removing
Direct pulp cap. When a pinpoint exposure (one millimeter the affected tooth if perforation causes loss of supportive
or less)17 of the pulp is encountered during cavity preparation bone and/or clinical signs of infection and inflammation.48-51
or following a traumatic injury, a biocompatible radiopaque There should be no harm to the succedaneous tooth.
base such as MTA26,41-43 or calcium hydroxide44 may be placed
in contact with the exposed pulp tissue. The tooth is restored Nonvital pulp treatment for primary teeth diagnosed with irre-
with a material that seals the tooth from microleakage.8 versible pulpitis or necrotic pulp
• Indications: This procedure is indicated in a primary tooth Pulpectomy. Pulpectomy is a root canal procedure for pulp
with a normal pulp following a small pulpal exposure of one tissue that is irreversibly inflamed or necrotic due to caries or
millimeter or less when conditions for a favorable response trauma. The root canals are debrided and shaped with hand
are optimal.26,41-43 or rotary files52 and then irrigated. A recent systematic review
• Objectives: The tooth’s vitality should be maintained. No showed no difference in success when irrigating with chlor-
post-treatment signs or symptoms such as sensitivity, pain, hexidine or one to five percent sodium hypochlorite or sterile
or swelling should be evident. Pulp healing and reparative water/saline.53,54 Because it is a potent tissue irritant, sodium
dentin formation should result. There should be no radio- hypochlorite must not be extruded beyond the apex.55 After
graphic signs of pathologic external or progressive internal the canals are dried, a resorbable material such as non-
root resorption or furcation/apical radiolucency. There reinforced zinc/oxide eugenol,56,57 iodoform-based paste4 or a
should be no harm to the succedaneous tooth. combination paste of iodoform and calcium hydroxide58,59 is
used to fill the canals. A recent systematic review reports that
Pulpotomy. A pulpotomy is performed in a primary tooth ZOE performed better long term than iodoform-based
when caries removal results in a pulp exposure in a tooth with pastes.53 The tooth then is restored with a restoration that
a normal pulp or reversible pulpitis or after a traumatic pulp seals the tooth from microleakage. Clinicians should evaluate
exposure12 and there is no radiographic sign of infection or non-vital pulp treatments for success and adverse events clini-
pathologic resorption. The coronal pulp is amputated, pulpal cally and radiographically at least every 12 months.53,54
hemorrhage controlled, and the remaining vital radicular pulp • Indications: A pulpectomy is indicated in a primary tooth
tissue surface is treated with a long-term clinically-successful with irreversible pulpitis or necrosis or a tooth treatment
medicament. Only MTA and formocresol are recommended as planned for pulpotomy in which the radicular pulp exhibits
the medicament of choice for teeth expected to be retained for clinical signs of irreversible pulpitis or pulp necrosis (e.g.,
24 months or more.17 Other materials or techniques such as suppuration, purulence) The roots should exhibit minimal
ferric sulfate, lasers, sodium hypochlorite, and tricalcium sili- or no resorption. When there is no root resorption present,
cate have conditional recommendations.17 The AAPD’s Use of pulpectomy is recommended over LSTR.53,54
vital Pulp Therapies in Primary Teeth with Deep Caries Lesions • Objectives: Following treatment, the radiographic infectious
recommended against the use of calcium hydroxide for pulpo- process should resolve in six months as evidenced by bone
tomy.17 After the coronal pulp chamber is filled with a suitable deposition in the pretreatment radiolucent areas, and pre-
base, the tooth is restored with a restoration that seals the treatment clinical signs and symptoms should resolve within
tooth from microleakage. If there is sufficient supporting a few weeks. There should be radiographic evidence of suc-
enamel remaining, amalgam or composite resin can provide a cessful filling without gross overextension or underfilling.57-59
functional alternative when the primary tooth has a life span The treatment should permit resorption of the primary
of two years or less.45-47 However, for multisurface lesions, a tooth root and filling material to permit normal eruption of
stainless steel crown is the restoration of choice.17 the succedaneous tooth. There should be no pathologic root
• Indications: The pulpotomy procedure is indicated when resorption or furcation/apical radiolucency.
caries removal results in pulp exposure in a primary tooth
with a normal pulp or reversible pulpitis or after a traumatic

Lesion sterilization/tissue repair. LSTR is a procedure that This liner must be followed by a well-sealed restoration
usually has no instrumentation of the root canals but, instead, to minimize bacterial leakage from the restoration-dentin
an antibiotic mixture is placed in the pulp chamber which is interface.23 Adverse post-treatment signs or symptoms such
intended to disinfect the root canals.53,54 After opening the as sensitivity, pain, or swelling should not occur.
pulpal chamber of a necrotic tooth, the canal orifices are
enlarged using a large round bur to create medication Apexogenesis (root formation). Apexogenesis is a histological
receptacles. The walls of the chamber are cleaned with term used to describe the continued physiologic development
phosphoric acid and then rinsed and dried.60 A three antibi- and formation of the root’s apex. Formation of the apex in
otic mixture of clindamycin, metronidazole, and ciprofloxacin vital young permanent teeth can be accomplished by im-
is combined with a liquid vector of polyethylene glycol and plementing the appropriate vital pulp therapy described in
macrogol to form a paste placed directly into the medication this section (i.e., indirect pulp treatment, direct pulp capping,
receptables and over the pulpal floor.60 It then is covered partial pulpotomy for carious exposures and traumatic
with a glass-ionomer cement and restored with a stainless steel exposures).
crown.60 Previous studies have used minocycline in place of
clindamycin61, but there are concerns about staining when a Indirect pulp treatment. IPT is a procedure performed in a
tetracycline-like drug is used.62 Although similar success rates tooth with a diagnosis of reversible pulpitis and deep caries
have been reported whether minocycline or clindamycin is that might otherwise need endodontic therapy if the decay was
used62, a more recent systematic review concluded statistically completely removed.12 In recent years, rather than completing
significant less success using a tetracycline mix versus a mix the caries removal in two appointments, the focus has been to
without tetracycline53. Therefore, the AAPD’s Use of Non-Vital excavate as close as possible to the pulp, place a protective liner,
Pulp Therapies in Primary Teeth recommends antibiotic and restore the tooth without a subsequent reentry to remove
mixtures used in LSTR should not include tetracycline.54 any remaining affected dentin.63,64 The risk of this approach is
• Indications: LSTR is indicated for a primary tooth with either an unintentional pulp exposure or irreversible pulpitis.64
irreversible pulpitis or necrosis or a tooth treatment planned When there is concern for pulp exposure, the step-wise excava-
for pulpotomy in which the radicular pulp exhibits clinical tion of deep caries may be considered.16 This approach involves
signs of irreversible pulpitis or pulp necrosis (e.g., suppura- a two-step process. The first step is the removal of carious
tion, purulence). Root resorption and strategic tooth position dentin along the dentin-enamel junction and excavation of
in the arch should be considered prior to treatment. When only the outermost infected dentin, leaving a carious mass over
a tooth is to be maintained for less than twelve months and the pulp. The objective is to change the cariogenic environ-
exhibits root resorption, LSTR is preferred to pulpectomy.53,54 ment in order to decrease the number of bacteria, close the
• Objectives: Following treatment, the radiographic infectious remaining caries from the biofilm of the oral cavity, and slow
process should resolve as evidenced by bone deposition in or arrest the caries development.65-67 This interim restoration
the pretreatment radiolucent areas and pretreatment clinical should be able to be maintained for up to 12 months.16 The
signs and symptoms should resolve. second step is the removal of the remaining caries and place-
ment of a final restoration. Critical to both steps of excavation
Immature permanent teeth is the placement of a well-sealed restoration.23 A recent
Vital pulp therapy for teeth diagnosed with a normal pulp or meta-analysis has shown that long term success rates are
reversible pulpitis equivalent for partial caries removal or stepwise caries removal
Protective liner. A protective liner is a thinly-applied material with greater than 96 percent of teeth treated remaining vital
placed on the pulpal surface of a deep cavity preparation, after two years.68
covering exposed dentin tubules, to act as a protective barrier • Indications: IPT is indicated in a permanent tooth with
between the restorative material or cement and the pulp. Place- deep caries that exhibits no pulpitis or has been diagnosed
ment of a thin protective liner such as MTA, trisilicate as reversible pulpitis when the deepest carious dentin is not
cements, calcium hydroxide, or other biocompatible material removed to avoid a pulp exposure. The pulp is judged by
is at the discretion of the clinician.19 The liner must be followed clinical and radiographic criteria to be vital and able to heal
by a well-sealed restoration to minimize bacterial leakage from from the carious insult.
the restoration-dentin interface.23 • Objectives: The intermediate and/or final restoration should
• Indications: In a tooth with a normal pulp, when caries is seal completely the involved dentin from the oral environ-
removed for a restoration, a protective liner may be placed ment. The vitality of the tooth should be preserved. No
in the deep areas of the preparation to minimize pulp injury, post-treatment signs or symptoms such as sensitivity, pain,
promote pulp tissue healing, and/or minimize postoperative or swelling should be evident. There should be no radio-
sensitivity. graphic evidence of internal or external root resorption or
• Objectives: The placement of a liner in a deep area of the other pathologic changes. Teeth with immature roots should
preparation is utilized to preserve the tooth’s vitality, promote show continued root development and apexogenesis.
pulp tissue healing, and facilitate tertiary dentin formation.

Direct pulp cap. When a small exposure of the pulp is is covered with calcium hydroxide77,78 or MTA12,79. MTA may
encountered during cavity preparation and after hemorrhage cause tooth discoloration.80,81 The two versions (light and gray)
control is obtained, the exposed pulp is capped with a have been shown to have similar properties.82,83 While calcium
material such as calcium hydroxide44,69 or MTA69 prior to hydroxide has been demonstrated to have long-term success,
placing a restoration that seals the tooth from microleakage.23 MTA results in more predictable dentin bridging and pulp
• Indications: Direct pulp capping is indicated for a perma- health.75 MTA (at least 1.5 millimeters thick) should cover
nent tooth that has a small carious or mechanical exposure the exposure and surrounding dentin, followed by a layer of
in a tooth with a normal pulp. light-cured resin-modified glass ionomer.79 A restoration that
• Objectives: The tooth’s vitality should be maintained. No seals the tooth from microleakage is placed.
post-treatment clinical signs or symptoms of sensitivity, • Indications: This pulpotomy is indicated for a vital,
pain, or swelling should be evident. Pulp healing and traumatically-exposed, young permanent tooth, especially
reparative dentin formation should occur. There should one with an incompletely formed apex
be no radiographic evidence of internal or external root re- • Objectives: The remaining pulp should continue to be vital
sorption, periapical radiolucency, abnormal calcification, or after partial pulpotomy. There should be no adverse clinical
other pathologic changes. Teeth with immature roots should signs or symptoms of sensitivity, pain, or swelling. There
show continued root development and apexogenesis. should be no radiographic signs of internal or external re-
sorption, abnormal canal calcification, or periapical radio-
Partial pulpotomy for carious exposures. The partial pulpot- lucency post-operatively. Teeth with immature roots should
omy for carious exposures is a procedure in which the show continued normal root development and apexogenesis.
inflamed pulp tissue beneath an exposure is removed to a
depth of one to three millimeters or deeper to reach healthy Complete pulpotomy. A complete or traditional pulpotomy
pulp tissue. Pulpal bleeding must be controlled by irrigation involves complete surgical removal of the coronal vital pulp
with a bacteriocidal agent such as sodium hypochlorite or tissue followed by placement of a biologically acceptable ma-
chlorhexidine51,70,71 before the site is covered with calcium terial in the pulp chamber and restoration of the tooth.6
hydroxide12 or MTA.72-74 While calcium hydroxide has been Compared to the traditionally-used calcium hydroxide, MTA
demonstrated to have long-term success, MTA results in more and tricalcium silicate exhibit superior long-term seal and
predictable dentin bridging and pulp health.75 MTA (at least reparative dentin formation leading to a higher success rate.84-86
1.5 millimeters thick) should cover the exposure and surround- • Indications: A full pulpotomy is indicated in immature
ing dentin followed by a layer of light cured resin-modified permanent teeth with cariously exposed pulp as an interim
glass ionomer.69 A restoration that seals the tooth from procedure to allow continued root development (apexogen-
microleakage is placed. esis). It also may be performed as an emergency procedure
• Indications: A partial pulpotomy is indicated in a young for temporary relief of symptoms until a definitive root
permanent tooth for a carious pulp exposure in which the canal treatment can be accomplished.6
pulpal bleeding is controlled within several minutes. The • Objectives: Full pulpotomy procedure in a vital permanent
tooth must be vital, with a diagnosis of normal pulp or tooth aims to preserve the vitality of remaining radicular
reversible pulpitis. pulp.3 The objective is to prevent adverse clinical signs and
• Objectives: The remaining pulp should continue to be vital symptoms, obtain radiographic evidence of sufficient root
after partial pulpotomy. There should be no adverse clini- development for endodontic treatment, prevent breakdown
cal signs or symptoms such as sensitivity, pain, or swelling. of periradicular tissues, and to prevent resorptive defects
There should be no radiographic sign of internal or external or accelerated canal calcification as determined by periodic
resorption, abnormal canal calcification, or periapical radio- radiographic evaluation.6
lucency postoperatively. Teeth having immature roots should
continue normal root development and apexogenesis. Nonvital pulp treatment
Pulpectomy (conventional root canal treatment). Pulpectomy
Partial pulpotomy for traumatic exposures (Cvek pulpotomy). in apexified permanent teeth is conventional root canal
The partial pulpotomy for traumatic exposures is a procedure (endodontic) treatment for exposed, infected, and/or necrotic
in which the inflamed pulp tissue beneath an exposure that teeth to eliminate pulpal and periradicular infection. In all
is four millimeters or less in size76 is removed to a depth of cases, the entire roof of the pulp chamber is removed to gain
one to three millimeters or more to reach the deeper healthy access to the canals and eliminate all coronal pulp tissue.
tissue. While literature indicates that a Cvek pulpotomy may Following cleaning, disinfection, and shaping of the root canal
be completed up to nine days after an exposure, there is no system, obturation of the entire root canal is accomplished
evidence on tooth outcomes with longer periods of waiting with a biologically-acceptable semi-solid or solid filling
time.76 Pulpal bleeding is controlled using irrigants such as material.6
sodium hypochlorite or chlorhexidine,70,71 and the site then

• Indications: Pulpectomy or conventional root canal treat- fected root canal space in the former therapy is filled with the
ment is indicated for a restorable permanent tooth with a host’s own vital tissue and the canal space in the latter therapy
closed apex that exhibits irreversible pulpitis or a necrotic is filled with biocompatible foreign materials.
pulp. For root canal-treated teeth with unresolved peri- • Indications: This procedure is indicated for nonvital perma-
radicular lesions, root canals that are not accessible from the nent teeth with incompletely formed roots.
conventional coronal approach, or calcification of the root • Objectives: This procedure should result in increased width
canal space, endodontic treatment of a more specialized of the root walls and may lead to increase in root length,
nature may be indicated. both confirmed by radiographic evaluation. Adverse post-
• Objectives: There should be evidence of a successful filling treatment clinical signs or symptoms of sensitivity, pain,
without gross overextension or underfilling in the presence or swelling should not be evident. There should be no
of a patent canal. There should be no adverse post-treatment radiographic evidence of external root resorption, lateral
signs or symptoms such as prolonged sensitivity, pain, or root pathosis, root fracture, or breakdown of periradicular
swelling, and there should be evidence of resolution of supporting tissues during or following therapy. The tooth
pretreatment pathology with no further breakdown of peri- should continue to erupt, and the alveolus should continue
radicular supporting tissues clinically or radiographically. to grow in conjunction with the adjacent teeth.
Apexification (root end closure). Apexification is a method. References

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658-68.

BEST PRACTICES: DEVELOPING DENTITION AND OCCLUSION
Management of the Developing Dentition and

Occlusion in Pediatric Dentistry
2019 of the developing dentition and occlusion in pediatric dentistry.
Purpose responsibility to recognize, diagnose, and manage or refer

The American Academy of Pediatric Dentistry (AAPD) abnormalities in the developing dentition as dictated by the
recognizes the importance of managing the developing denti- complexity of the problem and the individual clinician’s
tion and occlusion and its effect on the well-being of infants, training, knowledge, and experience.6
children, and adolescents. Management includes the recog- Many factors can affect the management of the developing
nition, diagnosis, and appropriate treatment of dentofacial dental arches and minimize the overall success of any treat-
abnormalities. These recommendations are intended to set ment. The variables associated with the treatment of the
forth objectives for management of the developing dentition developing dentition that will affect the degree to which
and occlusion in pediatric dentistry. treatment is successful include, but are not limited to:
1. chronological/mental/emotional age of the patient
Methods and the patient’s ability to understand and cooperate
Recommendations on management of the developing dentition in the treatment.
and occlusion were developed by the Developing Dentition 2. intensity, frequency, and duration of an oral habit.
Subcommittee of the Clinical Affairs Committee and adopted 3. parental support for the treatment.
in 1990.1 This document by the Council of Clinical Affairs 4. compliance with clinician’s instructions.
is a revision of the previous version, last revised in 2014.2 5. craniofacial configuration.
This revision is based upon a new PubMed /MEDLINE ®
search using the terms: tooth ankylosis, Class II malocclusion,
6. craniofacial growth.
7. concomitant systemic disease or condition.
Class III malocclusion, interceptive orthodontic treatment, 8. accuracy of diagnosis.
evidence-based, dental crowding, ectopic eruption, dental im- 9. appropriateness of treatment.
paction, obstructive sleep apnea syndrome (OSAS), occlusal 10. timing of treatment.
development, craniofacial development, craniofacial growth, A thorough clinical examination, appropriate pretreatment
airway, facial growth, oligodontia, oral habits, occlusal wear records, differential diagnosis, sequential treatment plan, and
and dental erosion, anterior crossbite, posterior crossbite, space progress records are necessary to manage any condition affect-
maintenance, third molar development, and tooth size/arch ing the developing dentition.
length discrepancy; fields: all; limits: within the last 10 years, Clinical examination should include:
humans, English, and birth through age 18. Papers for review 1. Facial analysis to:
were chosen from these searches and from references within a. identify adverse transverse growth patterns includ-
selected articles. When data did not appear sufficient or were ing asymmetries (maxillary and mandibular);
inconclusive, recommendations were based upon expert and/ b. identify adverse vertical growth patterns;
or consensus opinion by experienced researchers and clinicians. c. identify adverse sagittal (anteroposterior [AP])
growth patterns and dental AP occlusal dishar-
Background monies; and
Guidance of eruption and development of the primary, mixed, d. assess esthetics and identify orthopedic and ortho-
and permanent dentitions is an integral component of com- dontic interventions that may improve esthetics and
prehensive oral health care for all pediatric dental patients. resultant self-image and emotional development.
Such guidance should contribute to the development of a
permanent dentition that is in a stable, functional, and esthe-
tically acceptable occlusion and normal subsequent dentofacial ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. AP: Anteroposterior.
development. Early diagnosis and successful treatment of
CBCT: Cone-beam computed tomography. EE: Ectopic eruption.
developing malocclusions can have both short-term and long- OSAS: Obstructive sleep apnea syndrome. PFE: Primary failure of
term benefits while achieving the goals of occlusal harmony eruption. TMD: Temporomandibular joint dysfunction.
and function and dentofacial esthetics.3-5 Dentists have the

2. Intraoral examination to: 1. establish the relative contributions of the soft tissue
a. assess overall oral health status; and and dental and skeletal structures to the patient’s
b. determine the functional status of the patient’s malocclusion.
occlusion. 2. prioritize problems in terms of relative severity.
3. Functional analysis to: 3. detect favorable and unfavorable interactions that may
a. determine functional factors associated with the result from treatment options for each problem area.
malocclusion; 4. establish short-term and long-term objectives.
b. detect deleterious habits; and 5. summarize the prognosis of treatment for achieving
c. detect temporomandibular joint dysfunction stability, function, and esthetics.
(TMD), which may require additional diagnostic A sequential treatment plan will:
procedures. 1. establish timing priorities for each phase of therapy.
2. establish proper sequence of treatments to achieve
Diagnostic records may be needed to assist in the evaluation short-term and long-term objectives.
of the patient’s condition and for documentation purposes. 3. assess treatment progress and update the biomechan-
Prudent judgment is exercised to decide the appropriate records ical protocol accordingly on a regular basis.
required for diagnosis of the clinical condition.7
Diagnostic orthodontic evaluations fall into three major Stages of development of occlusion
categories: (1) health of the teeth and oral structures, (2) General considerations and principles of management: The
alignment and occlusal relationships of the teeth, and (3) facial stages of occlusal development include:
and jaw proportions.7 1. Primary dentition: Beginning in infancy with the
Diagnostic records may include: eruption of the first tooth, usually about six months
1. Extraoral and intraoral photographs to: of age, and complete from approximately three to
a. supplement clinical findings with oriented facial six years of age when all primary teeth are erupted.
and intraoral photographs; and 2. Mixed dentition: From approximately age six to 13,
b. establish a database for documenting facial primary and permanent teeth are present in the
changes during treatment. mouth. This stage can be divided further into early
2. Diagnostic dental casts to: mixed and late mixed dentition.
a. assess the occlusal relationship; 3. Adolescent dentition: All succedaneous teeth have
b. determine arch length requirements for intraarch erupted, second permanent molars may be erupted
tooth size relationships; or erupting, and third molars have not erupted.
c. determine arch length requirements for interarch 4. Adult dentition: All permanent teeth are present.7,8
tooth size relationships; and
d. determine location and extent of arch asymmetry. Historically, orthodontic treatment was provided mainly for
3. Intraoral and panoramic radiographs to: adolescents. Interest continues to be expressed in the concept
a. establish dental age; of interceptive (early) treatment as well as in adult treatment.
b. assess eruption problems; Treatment and timing options for the growing patient have
c. estimate the size and presence of unerupted teeth; increased and continue to be evaluated by the research com-
and munity.9,10 Many clinicians seek to modify skeletal, muscular,
d. identify dental anomalies/pathology. and dentoalveolar abnormalities before the eruption of the
4. Lateral and AP cephalograms to: full permanent dentition.
a. produce a comprehensive cephalometric analysis A thorough knowledge of craniofacial growth and develop-
of the relative dental and skeletal components in ment of the dentition, as well as orthodontic treatment, must
the AP, vertical, and transverse dimensions; be used in diagnosing and reviewing possible interceptive
b. establish a baseline growth record for longitudinal treatment options before recommendations are made to parents.
assessment of growth and displacement of the Treatment is beneficial for many children, but may not be
jaws; and indicated for every patient with a developing malocclusion.
c. determine dental maturity relative to skeletal
maturity and chronological age. Treatment considerations: The developing dentition should
5. Other diagnostic views (e.g., magnetic resonance be monitored throughout eruption. This monitoring at regular
imaging, cone-beam computed tomographic images clinical examinations should include, but not be limited to,
[CBCT]) for hard and soft tissue imaging as diagnosis of missing, supernumerary, developmentally de-
indicated by history and clinical examination. fective, and fused or geminated teeth; ectopic eruption; space
and tooth loss secondary to caries; and periodontal and pulpal
A differential diagnosis and diagnostic summary are health of the teeth.
completed to:

Radiographic examination, when necessary11 and feasible, Treatment objectives: At each stage, the objectives of
should accompany clinical examination. Diagnosis of anomalies intervention/treatment include managing adverse growth,
of primary or permanent tooth development and eruption correcting dental and skeletal disharmonies, improving esthe-
should be made to inform the patient’s parent and to plan tics of the smile and the accompanying positive effects on
and recommend appropriate intervention. This evaluation is self-image, and improving the occlusion.
ongoing throughout the developing dentition, at all stages.7,8 1. Primary dentition stage: Habits and crossbites should
1. Primary dentition stage: Anomalies of primary teeth be diagnosed and, if predicted not likely to be self-
and eruption may not be evident/diagnosable prior correcting, they should be addressed as early as feasible
to eruption, due to the child’s not presenting for to facilitate normal occlusal relationships. Parents
dental examination or to a radiographic examination should be informed about findings of adverse
not being possible in a child due to age or behavior. growth and developing malocclusions. Interventions/
Evaluation, however, should be accomplished when treatment can be recommended if diagnosis can be
feasible. The objectives of evaluation include identi- made, treatment is appropriate and possible, and
fication of: parents are supportive and desire to have treatment
a. all anomalies of tooth number and size (as done.
previously noted); 2. Early mixed dentition stage: Treatment consideration
b. anterior and posterior crossbites; should address:
c. presence of habits along with their dental and a. habits;
skeletal sequelae; b. arch length shortage;
d. openbite; and c. intervention for crowded incisors;
e. airway problems. d. intervention for ectopic teeth;
Radiographs are taken with appropriate clinical indi- e. holding of leeway space;
cators or based upon risk assessment/history. f. crossbites;
2. Early mixed dentition stage: The objectives of evalu- g. openbite;
ation continue as noted for the primary dentition h. surgical needs; and
stage. Palpation for unerupted teeth should be part i. adverse skeletal growth.
of every examination. Panoramic, occlusal, and peria- Intervention for ectopic teeth may include extrac-
pical radiographs, as indicated at the time of eruption tions of primary teeth and space maintenance/
of the lower incisors and first permanent molars, regaining to aid erupting teeth and reduce the risk
provide diagnostic information concerning: of need for permanent tooth extraction or surgical
a. unerupted teeth; bracket placement for orthodontic traction. Treat-
b. missing, supernumerary, fused, and geminated teeth; ment should take advantage of the child’s growth
c. tooth size and shape (e.g., peg or small lateral and should be aimed at prevention of adverse dental
incisors); relationships and skeletal growth.
d. positions (e.g., ectopic first permanent molars); 3. Late mixed dentition stage: Intervention for treat-
e. developing skeletal discrepancies; and ment of skeletal disharmonies and crowding may be
f. periodontal health. instituted at this stage.
Space analysis can be used to evaluate arch length 4. Adolescent dentition stage: In full permanent denti-
at the time of incisor eruption. tion, orthodontic diagnosis and treatment can provide
3. Late mixed dentition stage: The objectives of the the most functional, stable, and esthetic occlusion.
evaluations remain consistent with the prior stages, 5. Early adult dentition stage: Third molar position or
with an emphasis on evaluation for ectopic tooth space can be evaluated and, if indicated, the tooth/
positions, especially canines, premolars, and second teeth removed. Full orthodontic treatment should be
permanent molars. recommended if needed.
4. Adolescent dentition stage: If not instituted earlier,
orthodontic diagnosis and treatment should be Recommendations
planned for Class I crowded, Class II, and Class III Oral habits
malocclusions as well as posterior and anterior General considerations and principles of management: The
crossbites. Third molars should be monitored as to habits of nonnutritive sucking, bruxing, tongue thrust swallow
position and space, and parents should be informed and abnormal tongue position, self-injurious/self-mutilating
of the dentist’s observations. behavior, and OSAS are discussed in these recommendations.
5. Early adult dentition stage: Third molars should be Oral habits may apply negative forces to the teeth and
evaluated. If orthodontic diagnosis has not been dentoalveolar structures. The relationship between oral habits
accomplished, recommendations should be made as and unfavorable dental and facial development is associational
necessary. rather than cause and effect.12,13 Habits of sufficient frequency,

duration, and intensity may be associated with dentoalveolar associated with profound neurodisability due to severe brain
or skeletal deformations such as increased overjet, reduced damage.33 Management options include monitoring the lesion,
overbite, openbite, posterior crossbite, or increased facial height. odontoplasty, providing a bite-opening appliance, or extracting
The duration of force is more important than its magnitude14; the teeth.33
the resting pressure from the lips, cheeks, and tongue has the Research on the relationship between malocclusion and
greatest impact on tooth position as these forces are main- mouth breathing suggests that impaired nasal respiration
tained most of the time.15,16 may contribute to the development of increased facial height,
Nonnutritive sucking behaviors are considered normal in anterior open bite, increased overjet, and narrow palate, but it
infants and young children. Long-term nonnutritive sucking is not the sole or even the major cause of these conditions.34
habits (e.g., pacifier use, thumb/finger sucking) have been OSAS may be associated with narrow maxilla, crossbite,
associated with anterior open bite and posterior crossbite.12,15-19 low tongue position, vertical growth, increased overjet, and
Some evidence indicates that changes resulting from sucking openbite. 35-37 History associated with OSAS may include
habits persist past the cessation of the habit; therefore, it has snoring, observed apnea, restless sleep, daytime neurobehavioral
been suggested that early dental visits provide parents with abnormalities or sleepiness, and bedwetting. Physical findings
anticipatory guidance to help their children stop sucking may include growth abnormalities, signs of nasal obstruction,
habits by age 36 months or younger.12,15,16 adenoidal facies, and enlarged tonsils.34,38,39
Bruxism, defined as the habitual nonfunctional and force- The identification of an abnormal habit and the assessment
ful contact between occlusal surfaces, can occur while awake of its potential immediate and long-term effects on the cra-
or asleep. The etiology is multifactorial and has been reported niofacial complex and dentition should be made as early as
to include central factors (e.g., emotional stress,20 parasomnias,21 possible. The dentist should evaluate habit frequency, duration,
traumatic brain injury,22 neurologic disabilities23) and morpho- and intensity in all patients with habits. Intervention to
logic factors (e.g., malocclusion24, muscle recruitment25). The terminate the habit should be initiated if indicated, and
occlusal wear that may result from bruxism is important to parents should be provided with information regarding con-
differentiate from other forms of occlusal loss of enamel sequences of a habit as well as tools to help in elimination of
(e.g., erosion caused by diet or gastroesophageal reflux).26 the habit.12,13
Reported complications of bruxism include dental attrition,
headaches, TMD, and soreness of the masticatory muscles.20 Treatment considerations: Management of an oral habit is
Evidence indicates that juvenile bruxism is self-limiting and indicated whenever the habit is associated with unfavorable
does not persist in adults.27 The spectrum of bruxism man- dentofacial development or adverse effects on child health or
agement ranges from patient/parent education, occlusal splints, when there is a reasonable indication that the oral habit will
and psychological techniques to medications.21,22,28,29 result in unfavorable sequelae in the developing permanent
Tongue thrusting, an abnormal tongue position and dentition. Any treatment must be appropriate for the child’s
deviation from the normal swallowing pattern, may be asso- development, comprehension, and ability to cooperate. Habit
ciated with anterior open bite, abnormal speech, and ante- treatment modalities include patient/parent counseling, be-
rior protrusion of the maxillary incisors.30 There is no evidence havior modification techniques, myofunctional therapy,
that intermittent short-duration pressures, created when appliance therapy (extraoral and intraoral), or referral to
the tongue and lips contact the teeth during swallowing or other providers including, but not limited to, orthodontists,
chewing, have significant impact on tooth position.15,30 If the psychologists, myofunctional therapists, or otolaryngologists.
resting tongue posture is forward of the normal position, The child’s desire to stop the habit is beneficial for managing
incisor displacement is likely, but if resting tongue posture is oral habits.13
normal, a tongue thrust swallow has no clinical significance.15
Self-injurious or self-mutilating behavior (i.e., repetitive Treatment objectives: Treatment is directed toward decreasing
acts that result in physical injury to the individual) is ex- or eliminating the habit and minimizing potential deleterious
tremely rare in the normal child. Such behavior, however, is effects on the dentofacial complex.
a chronic condition more frequently seen in special needs
populations, having been associated with developmental delay Disturbances in number
or disabilities, psychiatric disorders, traumatic brain injuries, Congenitally missing teeth
and some syndromes.31,32 The spectrum of treatment options General considerations and principles of management: Hypo-
for developmentally disabled individuals includes pharmaco- dontia, the congenital absence of one or more permanent
logic management, behavior modification, and physical teeth, has a prevalence of 3.5 to 6.5 percent.40 Excluding third
restraint. 33 Dental treatment modalities include, among molars, the most frequently missing permanent tooth is the
others, lip-bumper and occlusal bite appliances, protective mandibular second premolar followed by the maxillary lateral
padding, and extractions. Some habits, such as lip-licking and incisor.40 In the primary dentition, hypodontia occurs less fre-
lip-pulling, are relatively benign in relation to an effect on quently (0.1 to 0.9 percent prevalence) and almost always
the dentition. Severe lip- and tongue-biting habits may be affects the maxillary incisors and first primary molars.41 The

chance of familial occurrence of one or two congenitally missing Supernumerary teeth (primary, permanent, and mesiodens)
teeth is to be differentiated from missing lateral incisors in General considerations and principles of management: Super-
cleft lip/palate42 and multiple missing teeth (six or more) due numerary teeth, or hyperdontia, can occur in the primary or
to ectodermal dysplasia or other syndromes43 as the treatment permanent dentition but are five times more common in the
usually differs. A congenitally missing tooth should be sus- permanent.44 Prevalence is reported in the primary dentition
pected in patients with cleft lip/palate, certain syndromes, and from 0.3-0.8 percent and the mixed dentition from 0.52 to
a familial pattern of missing teeth. In addition, patients with two percent.52-55 Between 80 and 90 percent of all super-
asymmetric eruption sequence, over-retained primary teeth, or numeraries occur in the maxilla, with half in the anterior
ankylosis of a primary mandibular second molar may have a area and almost all in the palatal position.52 A supernumerary
congenitally missing tooth.42,44,45 primary tooth is followed by a supernumerary permanent
tooth in one-third of the cases.56 Supernumerary teeth are
Treatment considerations: With congenitally missing perma- classified according to their form and location.52,57
nent maxillary incisor(s) or mandibular second premolar(s), During the early mixed dentition, 79 to 91 percent of
the decision to extract the primary tooth and close the space anterior permanent supernumerary teeth are unerupted. 45,53
orthodontically versus opening the space orthodontically and While more erupt with age, only 25 percent of all mesiodens
placing a prosthesis or implant depends on many factors. For (a permanent supernumerary incisor located at the midline)
maxillary laterals, the dentist may move the maxillary canine erupt spontaneously.52 Mesiodens can prevent or cause ectopic
mesially and use the canine as a lateral incisor or create space eruption of a central incisor. Less frequently, a mesiodens can
for a future lateral prosthesis or implant.13,46 cause dilaceration or resorption of the permanent incisor’s
Factors that influence the decision are: (1) patient age; (2) root. Dentigerous cyst formation involving the mesiodens, in
canine size and shape; (3) canine position; (4) child’s occlu- addition to eruption into the nasal cavity, has been reported.52
sion and amount of crowding; (5) bite depth; (6) profile; If there is an asymmetric eruption pattern of the maxillary
(7) smile line; and (8) quality and quantity of bone in the incisors, delayed eruption, an overretained primary incisor, or
edentulous area.46,47 Early extraction of the primary canine and/ ectopic eruption of an incisor, a supernumerary tooth can be
or lateral may be needed.46 Opening space for a prosthesis or suspected.41,42,53 Panoramic, occlusal, and periapical radiographs
implant requires less tooth movement, but the space needs to all can reveal a supernumerary tooth. To determine the super-
be maintained with an interim prosthesis, especially if an numerary tooth’s position, either a cone beam radiograph or
implant is planned. 43,46 Moving the canine into the lateral two periapical or occlusal films reviewed by the parallax rule is
position produces little facial change, but the resultant tooth recommended.52,54
size discrepancy often does not allow a canine guided occlu-
sion.45,46 Patients generally prefer space closure over implants.47 Treatment considerations: Management and treatment of
For a congenitally missing premolar, the primary molar hyperdontia differs if the tooth is primary or permanent. Pri-
may either be maintained or extracted with placement of a mary supernumerary teeth normally are accommodated into
prosthesis, autotransplantation, or orthodontic space closure.48-54 the arch and usually erupt and exfoliate without complications.56
Maintaining the primary second molar may cause occlusal Surgical extraction of unerupted anterior supernumerary teeth
problems due to its larger mesiodistal diameter, compared during the primary dentition can displace or damage the per-
to the second premolar.46 Reducing the width of the second manent incisor.52 Removal of an erupted mesiodens or other
primary molar is a consideration, but root resorption and permanent supernumerary incisor results in eruption of the
subsequent exfoliation may occur.13,46 In crowded arches or permanent adjacent normal incisor in 75 percent of the cases.52
with multiple missing premolars, extraction of the primary Extraction of an unerupted supernumerary during the early
molar(s) can be considered, especially in mild Class III mixed dentition (i.e., at age six to seven years when the
cases. 13,46,50 For a single missing premolar, if maintaining permanent crown has formed completely and the root length
the primary molar is not possible, placement of a prosthesis, is less than the crown height) allows for a normal eruptive
autotransplantation, or implant should be considered.13,47,50 force and eruption of the adjacent normal permanent in-
Preserving the primary tooth may be indicated in certain cisor.52-54,58 Later removal of the mesiodens reduces the likeli-
cases. However, maintaining a submerged/ankylosed tooth hood that the adjacent normal permanent incisor will erupt
may increase the likelihood of an alveolar defect which can on its own, especially if the apex is completed.52 Inverted conical
compromise later implant success. 50,51 Consideration for supernumerary teeth can be harder to remove if removal is
extraction and space maintenance may be indicated.50,51 Con- delayed, as they can migrate deeper into the jaw.53 After removal
sultation with an orthodontist and/or prosthodontist may be of the supernumerary tooth, clinical and radiographic follow-up
considered. is indicated in six months to determine if the normal incisor
is rupting. If there is no eruption after six to 12 months and
Treatment objectives: Treatment is directed toward an esthe- sufficient spaceexists, surgical exposure and orthodontic
tically pleasing occlusion that functions well for the patient. extrusion may be needed.52,59,60

Treatment objectives: Removal of supernumerary teeth should where little of the tooth is impacted under the primary second
facilitate eruption of permanent teeth and encourage normal molar, elastic or metal orthodontic separators can be placed
alignment. In cases where normal alignment or spontaneous to wedge the permanent first molar distally.61 For more severe
eruption does not occur, further orthodontic treatment is impactions, distal tipping of the permanent molar is re-
indicated. quired.61 Tipping action can be accomplished with brass
wires, removable appliances using springs, fixed appliances
Localized disturbances in eruption such as sectional wires with open coil springs,74 sling shot-type
Ectopic eruption appliances,75 or a Halterman appliance.76
General considerations and principles of management: Early diagnosis and treatment of impacted maxillary canines
Ectopic eruption (EE) of permanent first molars occurs due to can lessen the severity of the impaction and may stimulate
the molar’s abnormal mesioangular eruption path, resulting in eruption of the canine. Extraction of the primary canine is
an impaction at the distal prominence of the primary second indicated when the canine bulge cannot be palpated in the
molar’s crown.61,62 EE can be suspected if asymmetric eruption alveolar process and there is radiographic overlapping of the
is observed or if the mesial marginal ridge is noted to be canine with the formed root of the lateral during the mixed
under the distal prominence of the second primary molar.61,62 dentition.67,77,78 The use of rapid maxillary expansion alone79,80
EE of permanent molars can be diagnosed from bitewing or with cervical pull headgear81 in the early mixed dentition
or panoramic radiographs in the early mixed dentition.61,62 has been shown to increase the potential for eruption of
This condition occurs in up to three percent of the popula- palatally-displaced maxillary canines. When the impacted ca-
tion.61 EE of first permanent molars has been associated with nine is diagnosed at a later age (11 to 16 years), if the canine
transverse and sagittal crowding and is more common in the is not horizontal, extraction of the primary canine lessens the
maxillary arch and in children with cleft lip and palate. 62-64 severity of the permanent canine impaction and 75 percent
EE of second permanent molars occurs infrequently.65 EE of will erupt. 82 Extraction of the first primary molar also has
permanent molars is classified into two types. There are those been reported to allow eruption of first premolars and to assist
that self-correct and others that remain impacted. Previous in the eruption of the canines.83 This need can be determined
data suggested that 66 percent of EE permanent molars self- from a panoramic radiograph,84,85 although CBCT will provide
correct by age seven; 45,62 however, a recent cohort study greater localization of the impacted canine.86 Bonded ortho-
demonstrated that 71 percent self-correct by age nine.66 In dontic treatment normally is required to create space or
some cases, definitive treatment is indicated to manage and/ align the canine. Long-term periodontal health of impacted
or avoid early loss of the primary second molar and space canines after orthodontic treatment is similar to nonimpacted
loss. 61,62 Increased magnitude of impaction, increased canines, and there is insufficient data to conclude the best
resorption of the primary tooth, and bilateral occurrence were type of surgical technique.87,88
positively associated with irreversible ectopic eruption and Treatment of ectopically erupting incisors depends on the
may indicate the need for early intervention.66 etiology. Extraction of necrotic or over-retained pulpally-
The maxillary canine appears in an impacted position in treated primary incisors is indicated in the early mixed denti-
1.5 - 2 percent of the population.67 Maxillary canine impaction tion.73 Removal of supernumerary incisors in the early mixed
should be suspected when the canine bulge is not palpable, dentition will lessen ectopic eruption of an adjacent permanent
asymmetric canine eruption is evident, or peg shaped lateral incisor. 52 After incisor eruption, orthodontic treatment
incisors are present.67-71 Panoramic radiographs may demon- involving removable or banded therapy may be needed.
strate that the canine has an abnormal inclination and/or over-
laps the lateral incisor root. Additional potential radiographic Treatment objectives: Management of ectopically erupting
signs of maxillary canine impaction include enlarged follicular molars, canines, and incisors should result in improved
sac, lack of root resorption of primary canines, and presence eruptive positioning of the tooth. In cases where normal
of premolar impaction.69,70,72 alignment does not occur, subsequent comprehensive ortho-
Maxillary incisors can erupt ectopically or be impacted from dontic treatment may be necessary to achieve appropriate
supernumerary teeth in up to two percent of the population.57 arch form and intercuspation.
Incisors also can have altered eruption due to pulp necrosis
(following trauma or caries) or pulpal treatment of the primary Ankylosis
incisor. 73 EE of permanent incisors can be suspected after General considerations and principles of management:
trauma to primary incisors, with pulpally-treated primary Ankylosis is a condition in which the cementum of a tooth’s
incisors, with asymmetric eruption, or if a supernumerary root fuses directly to the surrounding bone.89 The periodontal
incisor is diagnosed.67,71 ligament is replaced with osseous tissue, rendering the tooth
immobile to eruptive change.89 An ankylosed tooth stays at
Treatment considerations: Treatment for ectopic molars the same vertical level, yet in a growing child appears to sub-
depends on how severe the impaction appears clinically and merge as the other teeth continue to erupt. Ankylosis can
radiographically. For mildly impacted first permanent molars, occur in the primary and permanent dentitions, with the most

common incidence involving primary molars. The incidence rior open bite in the presence of normal vertical growth, infra-
is reported to be between seven and 14 percent in the primary occlusion of affected teeth, and the inability to move affected
dentition.90 In the permanent dentition, ankylosis occurs most teeth orthodontically.103
frequently following luxation injuries.91 The reported incidence of PFE is between 0.01 and 0.06
Ankylosis is common in anterior teeth following trauma percent;104,105 however, some data suggests PFE may be mis-
and is referred to as replacement resorption. Periodontal diagnosed as infra-occlusion or ankylosis.106,107 PFE differs from
ligament cells are destroyed, and the cells of the alveolar bone ankylosis in that eruption fails to occur due to an imbalance
perform most of the healing. Over time, normal bony activity in resorptive and appositional factors related to tooth erup-
results in the replacement of root structure with osseous tion.108,109 Teeth with PFE are not initially ankylosed but may
tissue.90,91 Ankylosis can occur rapidly or gradually over time, become ankylosed when orthodontic forces are applied.110 A
in some cases as long as five years post trauma. It also may systematic review demonstrated 85 percent of patients with
be transient if only a small bony bridge forms then is resorbed PFE have another family member with the condition.100 PFE
with subsequent osteoclastic activity.92 has variable expression and has been associated with mutations
Ankylosis can be verified by clinical and radiographic means. in the autosomal dominant parathyroid hormone receptor
Submergence of the tooth is the primary recognizable sign, (PTH1R) gene.110-113 A sample of blood or saliva deoxyri-
but the diagnosis also can be made through percussion and bonucleic acid (DNA) can be used to test for mutations in
palpation.93 Radiographic examination also may reveal the loss PTH1R.112,114
of the periodontal ligament and bony bridging.89
Treatment considerations: Diagnosis of PFE should be based
Treatment considerations: With ankylosis of a primary molar, on a combination of clinical, radiographic, and genetic infor-
exfoliation usually occurs normally. Extraction is recommended mation.108-110 A positive family history also supports a diagnosis
if prolonged retention of the primary molar is noted. If a of PFE.102 Other than a few anecdotal reports, PFE is strongly
severe marginal ridge discrepancy develops, extraction should associated with the failure of orthodontically assisted eruption
be considered to prevent the adjacent teeth from tipping and or tooth movement.108,109 To that point, early orthodontic inter-
producing space loss 4,93 or vertical occlusal discrepancies. 94 vention of the affected teeth should be avoided.103,108,109,114 To
Replacement resorption of permanent teeth usually results in date there are no established mechanotherapeutic methods of
the loss of the involved tooth.90 modifying dentoalveolar growth for these patients.103,108,109,114
Mildly to moderately ankylosed primary molars without Space maintenance, up-righting adjacent teeth that have tipped
permanent successors may be retained and restored to function into the sites, prevention of supra-eruption in opposing arch,
in arches without crowding.94 Extraction of these molars can or modification of lateral tongue thrust habits may be addi-
assist in resolving crowded arches in complex orthodontic tional considerations.103,114 Once growth is complete, multi-
cases.95 Surgical luxation of ankylosed permanent teeth with disciplinary treatment options such as single tooth or segmental
forced orthodontic eruption has been described as an alternative osteotomies with immediate traction, or selective extractions
to premature extraction.96,97 followed by implants can be considered to create a function-
ing occlusion.108 Early extraction of first molars allowing the
Treatment objectives: Treatment of ankylosis should result in second molars to drift forward has also been suggested.103
the continuing normal development of the permanent denti-
tion. In the case of replacement resorption of a permanent Treatment objectives: Since best available evidence does not
tooth, appropriate prosthetic replacement should be planned. support early orthodontic intervention, treatment objectives
of PFE should involve reassurance and education about the
Primary failure of eruption eruption disorder and preparation for future prosthetic rehabil-
General considerations and principles of management: Primary itation.103 In some cases, early extraction can improve normal
failure of eruption (PFE) is an eruption disorder characterized development of the alveolus and permanent dentition.103
by partial or complete non-eruption of permanent teeth in the Objectives include space and intra-arch maintenance in
absence of any mechanical obstruction or syndrome.98 Failure preparation for future implants, prosthetic rehabilitation, or
in eruptive mechanisms prevent permanent successors from corticotomy-assisted tooth movement.103
following the eruption path after the exfoliation of deciduous
teeth.99 Posterior teeth are most commonly affected and one or Tooth size/arch length discrepancy and crowding
all four quadrants may be involved.100 Although typically associ- General considerations and principles of management:
ated with permanent teeth, examples in the primary dentition Arch length discrepancies include inadequate arch length and
have been noted.101 Two main phenotypes of PFE have been crowding of the dental arches, excess arch length and spacing,
identified: (1) All teeth distal to the most mesial non-erupted and tooth size discrepancy, often referred to as a Bolton dis-
tooth are affected, or (2) unerupted teeth do not follow the crepancy.115 These arch length discrepancies may be found in
pattern that all teeth distal to the most mesial involved tooth conjunction with complicating and other etiological factors
are also affected.102 Hallmark features of PFE include poste- including missing teeth, supernumerary teeth, and fused or

geminated teeth. Inadequate arch length with resulting incisor Additional treatment modalities may include, but are not
crowding is a common occurrence with various negative limited to: (1) interproximal reduction; (2) restorative bond-
sequelae and is particularly common in the early mixed denti- ing; (3) veneers; (4) crowns; (5) implants; and (6) orthognathic
tion.116-119 Studies of arch length in today’s children compared surgery.
to their parents and grandparents of 50 years ago indicate less
arch length, more frequent incisor crowding, and stable tooth Treatment objectives: Well-timed intervention can:
sizes.120-122 This implies that the problem of incisor crowding 1. prevent crowded incisors.
and ultimate arch length discrepancies may be increasing in 2. increase long-term stability of incisor positions.
numbers of patients and in amount of arch length shortage.121-123 3. decrease ectopic eruption and impaction of perma-
Arch length and especially crowding must be considered in nent canines.
the context of the esthetic, dental, skeletal, and soft tissue 4. reduce orthodontic treatment time and sequelae.
relationships. Mandibular incisors have a high relapse rate in 5. improve gingival health and overall dental health.116,128,129
rotations and crowding.116,118 Growth of the aging skeleton causes
further crowding and incisor rotations.124 Functional contacts Space maintenance
are diminished where rotations of incisors, canines, and General considerations and principles of management: The
premolars exist.125 Occlusal harmony and temporomandibular premature loss of primary teeth due to caries, infection, trauma,
joint health are impacted negatively by less functional contacts.125 ectopic eruption, or crowding deviates from the normal exfolia-
Initial assessment may be done in early mixed dentition, tion pattern and may lead to loss of arch length. Arch length
when mandibular incisors begin to erupt.116 Evaluation of avail- deficiency can produce or increase the severity of malocclusions
able space and consideration of making space for permanent with crowding, rotations, ectopic eruption, crossbite, excessive
incisors to erupt may be done initially utilizing appropriate overjet, excessive overbite, and unfavorable molar relation-
radiographs to ascertain the presence of permanent successors. ships.130 Whenever possible, restoration of carious primary teeth
Comprehensive diagnostic analysis is suggested, with evaluation should be attempted to avoid malocclusions that could result
of maxillary and mandibular skeletal relationships, direction from their extraction.131 The use of space maintainers to reduce
and pattern of growth, facial profile, facial width, muscle the prevalence and severity of malocclusion following prema-
balance, and dental and occlusal findings including tooth ture loss of primary teeth should be considered.13,132,133
positions, arch length analysis, and leeway space. Adverse effects associated with space maintainers include:
Derotation of teeth just after emergence in the mouth implies (1) dislodged, broken, and lost appliances; (2) plaque accumu-
correction before the transseptal fiber arrangement has been lation; (3) increase in microorganisms and increase in perio-
established.116,125 It has been shown that the transseptal fibers dontal index scores; (4) caries; (5) damage or interference with
do not develop until the cementoenamel junction of erupting successor eruption; (6) undesirable tooth movement; (7)
teeth pass the bony border of the alveolar process.125 Therefore, inhibition of alveolar growth; (8) soft tissue impingement; and
long-term stability of aligned incisors may be increased.126 (9) pain.130,134-140 Premature loss of a primary tooth, especially
in crowded dentitions, has the potential to cause loss of space
Treatment considerations: Treatment considerations may available for the succeeding permanent tooth, but there is a
include, but are not limited to: lack of consensus or evidence regarding the effectiveness of
1. gaining space for permanent incisors to erupt and space maintainers in preventing or reducing the severity of
become straight naturally through primary canine malocclusion.130,135,136,141-150
extraction and space/arch length maintenance with
holding arches. Extraction of primary or permanent Treatment considerations: It is prudent to consider space
teeth with the aim of alleviating crowding should maintenance when primary teeth are lost prematurely. Factors
not be undertaken without a comprehensive space to consider include: (1) specific tooth lost; (2) time elapsed since
analysis and a short- and long-term orthodontic treat- tooth loss; (3) occlusion and space assessment; (4) dental age;
ment plan. (5) presence and root development of permanent successor;
2. orthodontic alignment of permanent teeth as soon (6) amount of alveolar bone covering permanent successor;
as erupted and feasible, expansion and correction of (7) patient’s health history and medical status; (8) patient’s
arch length as early as feasible. cooperative ability; (9) active oral habits; and (10) oral
3. utilizing holding arches in the mixed dentition until hygiene.13,130,131
all permanent premolars and canines have erupted. The literature pertaining to the use of space maintainers
4. maintaining patient’s original arch form.125 specific to the loss of a particular primary tooth type include
5. interproximal stripping of the enamel of mandibular expert opinion, case reports, and details of appliance design.13,
132,133
primary canines to allow alignment of crowded lower Space maintainers can be designed as fixed unilateral
permanent lateral incisors.127 (band and loop, crown and loop, distal shoe), fixed bilateral
(lower lingual holding arch, Nance appliance, transpalatal arch),

or removable (partial dentures, Hawley type appliance). Vari- Treatment objectives: The goal of space regaining intervention
ations of these appliances have been described. Unilateral is the recovery of lost arch width and perimeter and/or im-
space maintainer kits as well as direct bonded techniques proved eruptive position of succedaneous teeth. Space regained
eliminate laboratory involvement and allow for single visit should be maintained until adjacent permanent teeth have
delivery; however, the literature describes mixed results on the erupted completely and/or until a subsequent comprehensive
longevity of these options compared to success rates of custom orthodontic treatment plan is initiated.
appliances.152-155
The placement and retention of space maintaining appli- Crossbites (dental, functional, and skeletal)
ances requires ongoing compliant patient behavior. Follow-up General considerations and principles of management: Cross-
of patients with space maintainers is necessary to assess inte- bites are defined as any abnormal buccal-lingual relation
grity of cement and to evaluate and clean the abutment between opposing incisors, molars, or premolars in centric
teeth.139 The appliance should function until the succedaneous relation.159-161 If the mid lines undergo a compensatory or
teeth have erupted into the arch. However, adjustment or new habitual shift when the teeth occlude in crossbite, this is
appliances may be necessary with continued development and termed a functional shift.157 A crossbite can be of dental or
changes in the dentition. skeletal origin or a combination of both.157
A simple anterior crossbite is of dental origin if the molar
Treatment objectives: The goal of space maintenance is to occlusion is Class I and the malocclusion is the result of an
prevent loss of arch length, width, and perimeter by main- abnormal axial inclination of maxillary and/or mandibular
taining the relative position of the existing dentition.13,132 anterior teeth. This condition should be differentiated from a
The AAPD recognizes the need for controlled randomized Class III skeletal malocclusion where the crossbite is the result
clinical trials to determine efficacy of space maintainers as well of the basal bone position.159 Posterior crossbites may be the
as analysis of costs and side effects of treatment. result of bilateral or unilateral lingual position of the maxillary
teeth relative to the mandibular posterior teeth due to tipping
Space regaining or alveolar discrepancy, or a combination. Most often, uni-
General considerations and principles of management: Some lateral posterior crossbites are the manifestation of a bilateral
of the more common causes of space loss within an arch are crossbite with a functional mandibular shift.161 Dental crossbites
(1) primary teeth with interproximal caries; (2) ectopically may be the result of tipping or rotation of a tooth or teeth. In
erupting teeth; (3) alteration in the sequence of eruption; (4) this case, the condition is localized and does not involve the
ankylosis of a primary molar; (5) dental impaction; (6) trans- basal bone. In contrast, skeletal crossbites involve disharmony
position of teeth; (7) loss of primary molars without proper of the craniofacial skeleton.161,162 Aberrations in bony growth
space management; (8) congenitally missing teeth; (9) abnor- may give rise to crossbites in two ways:
mal resorption of primary molar roots; (10) premature and 1. adverse transverse growth of the maxilla and mandible.
delayed eruption of permanent teeth; and (11) abnormal dental 2. disharmonious or adverse growth in the sagittal (AP)
morphology.13,130,133,156,157 Therefore, loss of space in the dental length of the maxilla and mandible.160,163
arch that interferes with the desired eruption of the perma-
nent teeth may require evaluation. Such growth aberrations can be due to inherited growth
The degree to which space is affected varies according to patterns, trauma, or functional disturbances that alter normal
the arch, site in the arch, and time elapsed since tooth loss.158 growth.161-163
The quantity and incidence of space loss are dependent upon
which adjacent teeth are present in the dental arch and their Treatment considerations: Crossbites should be considered
status.13,130 The amount of crowding or spacing in the dental in the context of the patient’s total treatment needs. Anterior
arch will determine the consequence of space loss.157 crossbite correction can: (1) reduce dental attrition; (2) improve
dental esthetics; (3) redirect skeletal growth; (4) improve the
Treatment considerations: Space can be maintained or regained tooth-to-alveolus relationship; (5) increase arch perimeter, (6)
with removable or fixed appliances.130,132 Some examples of help avoid periodontal damage, and (7) prevent the potential
fixed space regaining appliances are active holding arches, pen- for TMD.162,164 If enough space is available, a simple anterior
dulum appliances, Halterman-type appliances, and Jones jig. crossbite can be aligned as soon as the condition is noted.
Examples of removable space regaining appliances are Hawley Treatment options include acrylic incline planes, acrylic re-
appliance with springs, lip bumper, and headgear.132 If space tainers with lingual springs, or fixed appliances with springs.
regaining is planned, a comprehensive analysis should be If space is needed, an expansion appliance also is an option.160
completed prior to any treatment decisions. Some factors that Posterior crossbite correction can accomplish the same objec-
should be considered in the analysis include: dentofacial devel- tives and can improve the eruptive position of the succedaneous
opment, age at time of tooth loss, tooth that has been lost, teeth. Early correction of posterior crossbites with a mandibular
space available, and space needed.130,132 functional shift has been shown to improve functional condi-
tions significantly and largely eliminate morphological and

positional asymmetries of the mandible.30,165,166 Contemporary Clinicians may decide to provide interceptive treatment
evidence indicates a need for long-term studies to assess the based on other factors.169,174 Evidence suggests that, for some
possibility for spontaneous crossbite correction, as current children, interceptive Class II treatment may improve self-
proof is conflicting.167 Functional shifts should be eliminated esteem and decreases negative social experiences, although the
as soon as possible with early correction163 to avoid TMD and/ improvement may not be different longterm.174,179 Early Class
or asymmetric growth.161,167 Treatment can be completed with: II correction may improve facial convexity and/or reduce
1. equilibration. incidence of maxillary anterior tooth trauma.180-185 An overjet
2. appliance therapy (fixed or removable). in excess of three millimeters is associated with an increased
3. extractions. risk of incisor injury, with large overjets (>8 millimeters)
4. a combination of these treatment modalities to resulting in trauma in more than 40 percent of children.186,187
correct the alveolar constriction.167
Treatment considerations: Factors to consider when planning
Skeletal expansion with fixed or removable palatal expand- orthodontic intervention for Class II malocclusion are: (1)
ers can be utilized until mid line suture fusion occurs.157,159 facial growth pattern; (2) amount of AP discrepancy; (3) patient
Treatment decisions depend on the: age; (4) projected patient compliance; (5) space analysis; (6)
1. amount and type of movement (tipping versus bodily anchorage requirements; and (7) patient and parent desires.
movement, rotation, or dental versus orthopedic Treatment modalities include: (1) extraoral appliances head-
movement); gear; (2) functional appliances; (3) fixed appliances; (4) tooth
2. space available; extraction and interarch elastics; and (5) orthodontics with
3. AP, transverse, and vertical skeletal relationships; orthognathic surgery.157
4. growth status; and
5. patients cooperation. Treatment objectives: Treatment of a developing Class II mal-
occlusion should result in an improved overbite, overjet, and
Patients with crossbites and concomitant Class III skeletal intercuspation of posterior teeth and an esthetic appearance
patterns and/or skeletal asymmetry should receive compre- and profile compatible with the patient’s skeletal morphology.
hensive treatment as covered in the Class III malocclusion
section. Class III malocclusion
General considerations and principles of management: Class
Treatment objectives: Treatment of a crossbite should result III malocclusion (mesio-occlusion) involves a mesial relation-
in improved intramaxillary alignment and an acceptable ship of the mandible to the maxilla or mandibular teeth to
interarch occlusion and function.165 maxillary teeth. This relationship may result from dental
factors (malposition of the teeth in the arches), skeletal factors
Class II malocclusion (asymmetry, mandibular prognathism, and/or maxillary re-
General considerations and principles of management: Class trognathism), anterior functional shift of the mandible, or a
II malocclusion (distocclusion) may be unilateral or bilateral combination of these factors.188
and involves a distal relationship of the mandible to the The etiology of Class III malocclusions can be hereditary,
maxilla or the mandibular teeth to maxillary teeth. This rela- environmental, or both. Hereditary factors can include clefts
tionship may result from dental (malposition of the teeth in of the alveolus and palate as well as other craniofacial ano-
the arches), skeletal (mandibular retrusion and/or maxillary malies that are part of a genetic syndrome.189,190 Some environ-
protrusion), or a combination of dental and skeletal factors.6 mental factors are trauma, oral/digital habits, caries, and early
Results of randomized clinical trials indicate that Class II childhood OSAS.191
malocclusion can be corrected effectively with either a single
or two-phase regimen.168-171 Growth-modifying effects in some Treatment considerations: Treatment of Class III malocclu-
studies did not show an influence on the Class II skeletal sions is indicated to provide psychosocial benefits for the
pattern,171-173 while other studies dispute these findings.174,175 child patient by reducing or eliminating facial disfigurement
There is substantial variation in treatment response to growth and to reduce the severity of malocclusion by promoting
modification treatments (headgear or functional appliance) compensating growth.192 Interceptive Class III treatment has
and no reliable predictors for favorable growth response have been proposed for years and has been advocated as a necessary
been found.168,174 Some reports state interceptive treatment tool in contemporary orthodontics, with initiation in the
does not reduce the need for either premolar extractions or primary-early mixed dentition recommended.193-202 Factors to
orthognathic surgery,169,171 while others disagree with these consider when planning orthodontic intervention for Class
findings.176 Two-phase treatment results in significantly longer III malocclusion are: (1) facial growth pattern; (2) amount of
treatment time163,169,177 although the time spent in full bonded AP discrepancy; (3) patient age; (4) projected patient compli-
appliance therapy in the permanent dentition can be signifi- ance; and (5) space analysis.
cantly less.178

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BEST PRACTICES: TEMPOROMANDIBULAR DISORDERS
Acquired Temporomandibular Disorders in Infants,

Children, and Adolescents
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Acquired
2019 temporomandibular disorders in infants, children, and adolescents.
Purpose Prevalence of TMD in children and adolescents

The American Academy of Pediatric Dentistry (AAPD) TMDs have been identified as a major cause of nonodonto-
recognizes that disorders of the temporomandibular joint genic pain in the orofacial region.8 The reported prevalence
(TMJ), masticatory muscles, and associated structures occa- of TMD in infants, children, and adolescents varies widely in
sionally occur in infants, children, and adolescents. These the literature.9-14 This variation may be due to differences in
recommendations are intended to assist the practitioner in populations studied, diagnostic criteria, examination methods,
the recognition and diagnosis of temporomandibular disorder and inter- and/or intra-rater variations of examining practi-
(TMD) and to identify possible treatment options. It is tioners.15,16 The Diagnostic Criteria (DC) TMD examination
beyond the scope of this document to recommend the use protocol is used in research settings to decrease variability in
of specific treatment modalities. diagnosis; however, few pediatric studies use this methodol-
ogy.17,18 One study using the criteria from the DC/TMD
Methods demonstrated an 11.9 percent prevalence of TMD in
Recommendations on acquired temporomandibular disorders adolescents.18 Most data suggests the prevalence of signs and
in infants, children, and adolescents were developed by the symptoms of TMD increases with age.14,18,19 One investigation
Clinical Affairs Committee—Temporomandibular Joint noted that TMD-related symptoms were rare in three- and
Problems in Children Subcommittee and adopted in 1990.1 five-year-olds whereas five to nine percent of 10- and 15-year-
This document by the Council of Clinical Affairs is a revision olds reported more severe symptoms.19 Another study found
of the previous version, last revised in 2015.2 The update 4.2 percent of adolescents aged 12-19 years reported TMD
included an electronic search using the terms: temporo- pain.16 A study of children in the primary dentition found
mandibular disorder, TMJ dysfunction, TMD AND adoles- that 34 percent of patients have signs and/or symptoms of
cents, TMD AND gender differences, TMD AND occlusion, TMD.20 This could be due, in part, to inclusion of muscular
TMD AND treatment; fields: all fields; limits: within the signs such as tenderness to palpation which can be difficult to
last 15 years, humans, English, clinical trials. The reviewers assess in young children.13,20 A systematic review and meta-
agreed upon the inclusion of 104 references to support these analysis of intra-articular TMD in children and adolescents
recommendations. When data did not appear sufficient or found a 16 percent prevalence of clinical signs and a 14 percent
were inconclusive, recommendations were based upon expert prevalence of TMJ sounds.13 Although TMD pain in children
and/or consensus opinion by experienced researchers and increases with age in both boys and girls, recent surveys have
clinicians. indicated a significantly higher prevalence of symptoms and
greater need for treatment in girls than boys.14,21 The develop-
Background ment of symptomatic TMD has been correlated with the onset
Definition of TMD of puberty in girls.22 For ages 16-19 years, 32.5 percent of girls
TMD is a collective term for a group of musculoskeletal and compared to 9.7 percent of boys reported school absences and
neuromuscular conditions which includes several clinical signs analgesic consumption due to TMD-related pain.21 Headaches
and symptoms involving the muscles of mastication, the TMJ, appear to be independently and highly associated with TMD
and associated structures.3 While TMD has been defined as in adolescents, with most occurring before the onset of jaw
“functional disturbances of the masticatory system”,4 some pain.23
researchers and clinicians include masticatory muscle dis-
orders,5 degenerative and inflammatory TMJ disorders,6 and
TMJ disk displacements5 under the umbrella of TMD.
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. CBCT: Cone-beam
computed tomography. DC: Diagnostic criteria. TMD: Temporo-
KEYWORDS: Pediatric, Adolescents, Temporomandibular Joint, Temporo- mandibular disorder. TMJ: Temporomandibular joint.
mandibular Disorders, Temporomandibular Joint Dysfunction Syndrome.

Etiology of TMD 3. Anatomical factors (skeletal and occlusal) and orthodontic

Temporomandibular disorders have multiple etiological treatment: The association of skeletal and occlusal factors
factors.24 There is insufficient evidence to reliably predict and the development of TMD is relatively weak. 27,46-48
which patients will or will not develop TMD.25 Predisposing Furthermore, the available data does not support that the
(risk) factors, precipitating (initiating) factors, and perpetuat- development of TMD is caused or improved by ortho-
ing (or sustaining) factors contribute to the development of dontic treatment,49-53 regardless of whether premolars were
TMDs.25 The available evidence base suggests a poor correla- extracted. 32 Changes in freeway dimension of the rest
tion between any single etiological factor and resulting signs position (normally two to four millimeters) may be impinged
(i.e., findings identified by the dentist during the examination) by occlusal changes, disease, muscle spasms, nervous
and symptoms (i.e., findings reported by the child or parent).26 tension, and/or restorative prosthetics.4 While most chil-
Alterations in any one or a combination of teeth, periodontal dren and adolescents may be able to compensate without
ligament, the TMJ, or the muscles of mastication may lead to problem, in others, failure of the masticatory system to
TMD.26 Furthermore, systemic and psychosocial factors may adapt may lead to greater risk of dysfunction. Although
reduce the adaptive capacity of the masticatory system and there is little evidence to implicate skeletal or occlusal
contribute to TMD.27 factors with TMD, the following have some association
Etiologic factors suggested as contributing to the develop- across studies:
ment of TMD are: a. skeletal anterior open bite.54,55
1. Macrotrauma: A common occurrence in childhood b. steep articular eminence of the temporal bone.27
because of falling, chin trauma is reported to be a factor c. overjet greater than six to seven millimeters.54-57
in the development of TMD in pediatric patients. 28-31 d. skeletal class II profile58
Additional macrotraumatic injuries occur due to motor e. class III malocclusion.16
vehicle accidents, sports, physical abuse, forceful intuba- f. unilateral posterior crossbite.46-55
tion, and third molar extraction. 31,32 Unilateral and bi- g. posterior crossbite.46
lateral intracapsular or subcondylar fractures are the
most common mandibular fractures in children.33 Closed Craniocervical posture has been suggested to be asso-
reduction and prolonged immobilization can result in ciated with occlusion and with dysfunction of the TMJ,
ankylosis.34,35 Improperly treated fractures may result in including abnormalities of the mandibular fossa, condyle,
facial asymmetry.34,35 Traumatic brain injury may accom- ramus, and disc.59 Cervical pain and dysfunction can be
pany mandibular fracture and other types of jaw injuries.31 a result of poor posture. 60 Cervical pain is frequently
Indirect trauma such as flexion-extension (whiplash) in- referred to orofacial structures and can be misinterpreted
juries may alter pain processing and lead to TMD as TMD.61
symptoms; however, a direct relationship between TMD 4. Psychosocial factors: Psychosocial factors may play a part
and indirect trauma has yet to be established.27 in the etiology of TMD.61,62 Behavioral factors such as
2. Microtrauma from parafunctional habits: Bruxism, somatization, anxiety, obsessive-compulsive feelings, and
clenching, hyperextension, and other repetitive habitual psychologic stress were predictors of TMD onset.61 Emo-
behaviors are thought to contribute to the development tional stress predisposes to clenching and bruxism which
of TMD by joint overloading that leads to cartilage in turn contribute to orofacial pain.63 Results from a case-
breakdown, synovial fluid alterations, and other changes control study indicate that management of stress and
within the joint.36 Bruxism may occur while the patient anxiety can mitigate the signs and symptoms of TMD.64
is asleep or awake; sleep bruxism is a different entity from Depression, anxiety, post-traumatic stress disorder, psy-
daytime bruxism. Sleep bruxism has been classified as a chologic distress, and sleep dysfunction may influence
sleep-related movement disorder.37 A study of 854 patients TMD prognosis and symptoms.64 Higher pain intensity
younger than 17 years old found the prevalence of in the orofacial region correlated with greater impact on
bruxism to be 38 percent,38 but studies generally do not quality of life including difficulty with prolonged jaw
distinguish between sleep or daytime bruxism. The liter- opening, eating hard/soft foods, and sleeping.64
ature on the association between parafunction and TMD 5. Systemic and pathologic factors: Systemic factors con-
in pediatric patients is contradictory.39-41 However, child- tributing to TMD include connective tissue diseases such
hood parafunction was found to be a predictor of the as rheumatoid arthritis, systemic lupus erythematosus,
same parafunction 20 years later.42 Other studies found juvenile idiopathic arthritis, and psoriatic arthritis.25,65,66
a significant association between reported bruxism and These systemic diseases occur as a result of imbalance of
TMD.34,44 Children who grind their teeth were found to pro-inflammatory cytokines which causes oxidative stress,
complain more often of pain and muscle tenderness when free radical formation, and ultimately joint damage.67
eating.45 Other examples of microtrauma include repeti- Other systemic factors may include joint hypermobility,
tive strain such as playing a wind instrument, fingernail genetic susceptibility, and hormonal fluctuations. Gener-
biting,25 or another activity in which the mouth is held alized joint laxity or hypermobility (e.g., Ehler Danlos
open outside of rest position.

syndrome) has been cited but has a weak association with • do you have pain when opening your mouth wide or
TMD.68,69 Pathologic hyperplasia, and condylar tumors when yawning?
represent a unique category of TMDs.66 • has your bite felt uncomfortable or unusual?
6. Genetic and hormonal factors: There is little research • does your jaw ever lock or go out?
regarding genetic susceptibility for development of • have you ever had an injury to your jaw, head, or neck?
TMD. Recently, study of catechol-O-methyl-transferase If so, when? How was it treated?
haplotypes found that the presence of one low pain • have you previously been treated for a temporomandi-
sensitivity haplotype decreased the risk of developing bular disorder? If so, when? How was it treated?
TMD.61 The role of hormones in the etiology of TMD
is debatable. Randomized controlled trials indicate that Physical assessment should include the following:24,25,27
estrogen does not play a role in the etiology of TMD, 1. palpation of the muscles of mastication and cervical
whereas cohort and case-controlled studies show the muscles for tenderness, pain, or pain referral patterns;
opposite. 27 Although the biological basis for gender- 2. palpation of the lateral capsule of the TMJs;
based disparity in TMD is unclear, the time course of 3. mandibular function and provocation tests;
symptoms is of note in females. Additional studies have 4. palpation and auscultation for TMJ sounds; and
shown that TMJ pain and other symptoms vary in 5. mandibular range of motion.
relation to phases of the menstrual cycle.70 The suggestion
of a hormonal influence in development of TMD is Evaluation of jaw movements including assessment of
supported clinically by a study of 3,428 patients who mandibular range of motion using a millimeter ruler (i.e.,
sought treatment for TMD. This study revealed that maximum unassisted opening, maximum assisted opening,
85.4 percent of patients seeking treatment were female maximum lateral excursion, maximum protrusive excursion)
and the peak age for treatment seeking was 33.8 years.70 and mandibular opening pattern (i.e., symmetrical vs. asym-
In a similar study of adolescents,71 15.1 percent of all metrical) may be helpful in the diagnosis of TMD. In addition,
patients evaluated for TMD were less than 20 years of both limited and excessive mandibular range of motion may
age, and girls accounted for 89.9 percent of patients be seen in TMD.25,27
aged 15-19 seeking care and 75.5 percent of patient TMJ imaging is recommended when there is a recent
six-14 years of age. history of trauma or developing facial asymmetry, or when
hard-tissue grinding or crepitus is detected.74 Imaging should
Diagnosing TMD also be considered in patients who have failed to respond to
All comprehensive dental examinations should include a conservative TMD treatment.36 TMJ imaging assessment may
screening evaluation of the TMJ and surrounding area.72,73 include:
Diagnosis of TMD is based upon a combination of historical • panoramic radiograph;
information, clinical examination, and/or craniocervical and • mandible radiographs including oblique views;
TMJ imaging.27 The findings are classified as symptoms and • conventional computed tomography (CT) or cone-beam
signs.72 These symptoms may include pain, headache, TMJ computed tomography (CBCT);
sounds, TMJ locking, and ear pain.24 Certain medical condi- • magnetic resonance imaging (both open and closed
tions are reported to occasionally mimic TMD. Among these mouth to view disc position); and
differential diagnoses are trigeminal neuralgia, central nervous • ultrasound.
system lesions, odontogenic pain, sinus pain, otological pain, TMJ arthography is not recommended as a routine diag-
developmental abnormalities, neoplasias, parotid diseases, nostic procedure.75-77 The readily available panoramic radio-
vascular diseases, myofascial pain, cervical muscle dysfunction, graph is reliable for evaluating condylar head morphology
and Eagle’s syndrome.8 Other common medical conditions and angulation but does not permit evaluation of the joint
(e.g., otitis media, allergies, airway congestion, rheumatoid space, soft tissues, or condylar motion.25 The panoramic ra-
arthritis) can cause symptoms similar to TMD.24 diograph may indicate osseous changes, but negative findings
Clinical and physical assessment of the patient may include do not rule out TMJ pathology.78 CBCT can be used to detect
history and determination of joint sounds, evaluation of boney abnormalities and fractures and to assess asymmetry,76-78
mandibular range of motion, appraisal of pain, evaluation for but it generates a much higher radiation burden than the
signs of inflammation, and select radiographic examination.24 panoramic image. Magnetic resonance imaging provides
A screening history, as part of the health history, may include visualization of soft tissues, specifically the position and contours
questions such as:25,27 of the TMJ disc, and can be used to detect inflammation.25,74,77
• do you have difficulty opening your mouth? Ultrasound is a noninvasive imaging method for viewing
• do you hear noises within your jaw joint? superficial lateral aspects of the TMJ.79
• do you have pain in or around your ears or your cheeks? TMD has been divided into two broad categories, TMJ
• do you have pain when chewing, talking, or using your disorders and masticatory muscles disorders,77 which are listed
jaws? below.

I. TMJ disorders: factors, anatomy of the TMJ, management options, and

A. joint pain: goals of therapy).27,81
1. arthralgia. • physical therapy (e.g., jaw exercises or transcutaneous
2. arthritis. electrical nerve stimulation [TENS], ultrasound, ionto-
B. joint disorders: phoresis, massage, TMJ distraction and mobilization,
1. disc-condyle complex disorders (disc displacement thermotherapy, coolant therapy).27,36,81,84-86
with reduction, disc displacement with reduction • behavioral therapy (e.g., biofeedback, relaxation training,
with intermittent locking, disc displacement with- cognitive behavioral therapy [CBT]) for developing be-
out reduction with limited opening, disc displace- havior coping strategies and modifying perceptions about
ment without reduction without limited opening). TMD, habit reversal and awareness of daytime clenching
2. hypomobility disorders (ankylosis, bony ankylosis, and bruxing, avoiding excessive chewing of hard foods
fibrous adhesions). or gum, voluntary avoidance of stressors, treatment of
3. hypermobility disorders (subluxation, luxation). co-morbid behavioral health conditions, obtaining ade-
C. joint diseases: quate, uninterrupted sleep).36,81,86
1. osteoarthritis (degenerative joint disease, condylysis/ • prescription medication (e.g., non-steroidal anti-
idiopathic condylar resorption, osteochondritis inflammatory drugs, anxiolytic agents, muscle relaxers).
dissecans, osteonecrosis). While antidepressants have proved to be beneficial, they
2. systemic arthritides such as rheumatoid arthritis, should be prescribed by a practitioner familiar with pain
idiopathic juvenile arthritis, spondyloarthrop- management.27,36,81,87
athies, psoriatic arthritis, infections arthritis, • occlusal splints. The goal of an occlusal appliance is to
Reiter syndrome, and crystal induced disease. provide orthopedic stability to the TMJ. These alter the
3. neoplasms. patient’s occlusion temporarily and may be used to de-
4. fractures (open and closed condylar and sub- crease parafunctional activity and pain. 83,88-90 Occlusal
condylar). splints may be made of hard or soft acrylic. The stabiliza-
II. Masticatory muscle disorders: tion type of splint covers all teeth on either the maxillary
A. muscle pain limited to orofacial region (myalgia, or mandibular arch and is balanced so that all teeth are
myofascial pain with spreading, myofascial pain with in occlusion when the patient is closed and the jaw is in
referral, tendonitis, myositis, spasm). a musculoskeletally stable position.8,36
B. muscle pain due to systemic/central disorders
(centrally mediated myalgia, fibromyalgia). Additional reversible therapies may include TMJ arthrocen-
C. movement disorders (dyskinesia, dystonia). tesis, TMJ injections, nerve blocks, acupuncture, trigger point
D. other muscle disorders (contracture, hypertrophy, injections, and off-label use of botulinum toxin A injections.91-95
neoplasm).
Irreversible therapies can include:
Treatment of TMD • occlusal adjustment (i.e., permanently altering the occlu-
The goals of TMD treatment include restoration of function, sion or mandibular position by selective grinding or full
decreased pain, decreased aggravating or contributing factors, mouth restorative dentistry).96 A systematic review and
and improved quality of life.80,81 Few studies document success meta-analysis demonstrated that occlusal alteration seems
or failure of specific treatment modalities for TMD in infants, to have no effect on TMD.97
children, and adolescents on a long-term basis. It has been sug- • orthodontics. This may include mandibular positioning
gested that simple, conservative, and reversible types of therapy devices designed to alter the growth or permanently
are effective in reducing most TMD symptoms in children.81,82 reposition the mandible (e.g., headgear, functional appli-
The focus of treatment should be to find a balance between ances). There is little evidence that orthodontic treatment
active and passive treatment modalities. Active modalities can prevent or relieve TMD.27,98,99
include participation of the patient whereas passive modalities • surgery. Surgical interventional includes orthognathic
may include wearing a stabilization splint. In a randomized trial, surgery, open joint TMJ surgery to removed diseased
adolescents undergoing occlusal appliance therapy combined synovium, and TMJ reconstruction.66 Data suggests sur-
with information attained a clinically significant improvement gery is limited in most situations to cases of severe joint
on the pain index.83 Combined approaches may be more suc- degeneration or destruction following trauma or tumor
cessful in treating TMD than single treatment modalities.81 resection.66,81,100
Treatment of TMD can be divided into reversible and irre-
versible treatment. Reversible therapies may include: Controversy surrounds the significance of signs and symp-
• patient education (e.g., explanation in clear and simple toms in children and adolescents, the value of certain diagnostic
terms describing the nature of the disorder, the signifi- procedures, and what constitutes appropriate therapy.58,101,102 It
cance of predisposing, precipitating, and perpetuating is not clear whether these signs and symptoms constitute

normal variation, preclinical features, or manifestations of a 7. Dolwich MF. Temporomandibular joint disk displace-
disease state.103 Whether these signs and symptoms warrant ment. In: Sessle BJ, Bryant PS, Dionne RA, eds. Temporo-
treatment as predictors of TMD in adulthood is questionable.42,103 mandibular Disorders and Related Pain Conditions.
Vol. 4. Seattle, Wash.: International Association for the
Recommendations Study of Pain Press; 1995:79-113.
Every comprehensive dental history and examination should 8. Okeson JP. Temporomandibular joint pains. In Bell’s Oral
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BEST PRACTICES: PERIODONTAL DISEASES
Classification of Periodontal Diseases in Infants,

Health Care Needs
Originating Council How to Cite: American Academy of Pediatric Dentistry. Classification
Council on Clinical Affairs of periodontal diseases in infants, children, adolescents, and individ-
uals with special health care needs. The Reference Manual of
Adopted Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric
2019 Dentistry; 2020:418-32.
Purpose patients and those medically compromised or with special

The American Academy of Pediatric Dentistry (AAPD) recog- health care needs affected by periodontal problems. A com-
nizes that although the prevalence of destructive forms of prehensive review of the 2017 World Workshop on the
periodontal disease is low among children and adolescents, this Classification of Periodontal and Peri-implant Diseases and
population can develop several forms of periodontal diseases Conditions including the rationale, criteria, and implementa-
and conditions most frequently associated with an underlying tion of the new classifications, is available in the June 2018
systemic or immunologic disorder.1-4 In addition, current and Journal of Periodontology (Table 1).6-28
early studies show that gingivitis occurs in half of the pop-
ulation by age of four or five years and peaks nearly to 100 Methods
percent at puberty.3 The prevalence of gingivitis can be similar This document presents an abbreviated overview of the new
to or greater than dental caries during childhood.1 Neverthe- classification of periodontal and peri-implant diseases and
less, when compared to dental caries, gingivitis in children has conditions.6-28 In addition to reviewing the proceeding papers
received much less attention in understanding the long-term from the 2017 World Workshop, an electronic search was
impact that chronic inflammation of the periodontal tissues
in childhood may have on overall health of the periodontium
®
conducted using PubMed /MEDLINE using the terms:
periodontal health AND children, periodontal health AND
throughout life.1 Therefore, it is critical that pediatric dental adolescents, gingival disease AND children, gingival disease
patients receive a periodontal assessment as part of their routine AND adolescents, periodontal disease AND children, perio-
dental visits. Early diagnosis ensures the greatest opportunity dontal disease AND adolescents, gingivitis AND prevalence,
for successful treatment, primarily by reducing etiological periodontitis AND prevalence, gingival disease AND preval-
factors, establishing appropriate therapeutic measures, and ence, periodontal disease AND prevalence, dental plaque
developing an effective periodic maintenance protocol.2 AND children, dental plaque AND adolescents; fields: all;
In 2017, the American Academy of Periodontology and limits: within the last 10 years, humans, English, and clinical
the European Federation of Periodontology co-sponsored the trials. From this search, 1588 articles matched these criteria
World Workshop on the Classification of Periodontal and and were evaluated by title and/or abstract. Information from
Peri-implant Diseases and Conditions. The objective of the 61 papers for review was chosen from this list and from
workshop was to update the previous disease classification references within selected articles. When data did not appear
established at the 1999 International Workshop for Classifi- sufficient or were inconclusive, recommendations were based
cation of Periodontal Diseases and Conditions. 5 One of the upon expert and/or consensus opinion by experienced re-
major highlights included the recategorization of three forms searchers and clinicians.
of periodontitis, the development of a multidimensional
staging and grading system for periodontitis, and the new
classification for peri-implant diseases and conditions.6 ABBREVIATIONS
The intent of this best practices document is to present an AAPD: American Academy of Pediatric Dentistry. ADA: American
abbreviated overview of the new classification of periodontal Dental Association. BoP: Bleeding on probing. CAL: Clinical attach-
ment loss. EPL: Endodontic-periodontal lesions. FDA: Food and Drug
and peri-implant diseases and conditions, including gingivitis. Administration. GH: Gingival health. ICD: International Statistical
In addition, this document aims to emphasize the key role Classif ication of Diseases and Related Health Problems. HIV/AIDS:
dentists have in diagnosing, treating and/or referring pediatric Human immunodeficiency virus and acquired immune deficiency
syndrome. mm: millimeters. PA: Periodontal abscess. PPD: Perio-
dontal probing depth. RBL: Radiographic bone loss. WHO: World
Health Organization.
KEYWORDS: Classification, Periodontal Health, Gingivitis, Periodontitis, Plaque.

Table 1. 2017 WORLD WORKSHOP ON THE CLASSIFICATION OF PERIODONTAL AND PERI-IMPLANT DISEASES AND CONDITIONS
( Adapted from Caton et al. 6 )
Periodontal Diseases and Conditions
Periodontal Health, Gingival Periodontitis Other Conditions Affecting

Diseases and Conditions Papapanou et al. 2018 Consensus Rept the Periodontium
Chapple et al. 2018 Rept Jepsen et al. 2018 Consensus Rept Jepsen et al. 2018 Consensus Rept
Trombelli et al. 2018 Case Definitions Tonetti et al. 2018 Case Definitions Papapanou et al. 2018 Consensus Rept
Periodontal Health, Gingival Necrotizing Periodontal Diseases Systemic Diseases or Conditions

Diseases and Conditions Herrera et al. 2018 Affecting the Periodontal
Lang & Bartold 2018 Supporting Tissues
1. Necrotizing gingivitis
2. Necrotizing periodontitis Albandar et al. 2018
1. Clinical gingival health on
an intact periodontium 3. Necrotizing stomatitis
2. Clinical gingival health on
a reduced periodontium Periodontal Abscesses and
a. Stable periodontitis patient Periodontitis as Manifestations Endodontic-Periodontal Lesions
b. Non-periodontitis patient of Systemic Diseases Papapanou et al. 2018
Jepsen, Caton et al. 2018 Consensus Rept Herrera et al. 2018
Albandar et al. 2018
Gingivitis – Dental Biofilm-induced Classification of these conditions should
Murakami et al. 2018 be based on the primary systemic disease Mucogingival Deformities
1. Associated with dental biofilm according to the International Statistical and Conditions
alone Classification of Diseases and Related Cortellini & Bissada 2018
2. Mediated by systemic or local Health Problems (ICD) codes 1. Gingival phenotype
risk factors 2. Gingival/soft tissue recession
3. Drug-influenced gingival 3. Lack of gingiva
enlargement Periodontitis 4. Decreased vestibular depth
Fine et al. 2018 5. Aberrant frenum/muscle position
Needleman et al. 2018 6. Gingival excess
Gingival Diseases – Non-dental Billings et al. 2018 7. Abnormal color
Biofilm-induced 8. Condition of the exposed root
1. Stages: Based on severity and surface
Holmstrup et al. 2018 complexity of management
1. Genetic/developmental Stage I: Initial periodontitis
disorders Stage II: Moderate periodontitis
Stage III: Severe periodontitis with Traumatic Occlusal Forces
2. Specific infections
3. Inflammatory and immune potential for additional tooth loss Fan & Caton 2018
conditions Stage IV: Severe periodontitis with 1. Primary occlusal trauma
4. Reactive processes potential for loss of the dentition 2. Secondary occlusal trauma
5. Neoplasms 2. Extent and distribution: localized; 3. Orthodontic forces
6. Endocrine, nutritional & generalized; molar-incisor distribution
metabolic diseases 3. Grades: Evidence or risk of rapid
7. Traumatic lesions progression, anticipated treatment
Tooth and Prosthesis-related Factors
8. Gingival pigmentation response
a. Grade A: Slow rate Ercoli & Caton 2018
b. Grade B: Moderate rate of 1. Localized tooth-related factors
progression 2. Localized dental prostheses-
c. Grade C: Rapid rate of progression related factors
Periodontal Diseases and Conditions ( Adapted from Berglundh and Armitage et al.9 )
Peri-implant Health Peri-implant Mucositis Peri-implantitis Peri-implant Soft and Hard Tissue
Araujo & Lindhe 2018 Heitz-Mayfield & Salvi 2018 Schwarz et al. 2018 Deficiencies
Hammerle & Tarnow 2018
© 2018 American Academy of Periodontol and European Federation of Periodontology. J Periodontol 2018;89(Supp 1):S1-S8.
John Wiley and Sons. Available at: “https://aap.onlinelibrary.wiley.com/doi/full/10.1002/JPER.18-0157”.

Background therapy outcomes by practitioners. 11,21 Four levels of perio-

Periodontal health, gingival diseases and conditions dontal health have been proposed, depending on whether (1)
Periodontal health the periodontium (attachment and bone level) is structurally
The World Health Organization (WHO) defines health as and clinically sound or reduced, (2) the ability to control local
“a state of complete physical, mental and social well-being and systemic modifying factors, as well as (3) the relative
and not merely the absence of disease or infirmity”. 29 Fol- treatment outcomes. These levels are: (1) pristine periodontal
lowing this framework, periodontal health is defined as the health, characterized by total absence of clinical inflammation,
absence of clinical inflammation associated with gingivitis, and physiological immune surveillance on a periodontium
periodontitis, or any other periodontal conditions, and may with normal support; (2) clinical periodontal health, charac-
include patients who have had a history of successfully treated terized by an absence or minimal levels of clinical inflamma-
gingivitis or periodontitis, or other periodontal conditions, tion in a periodontium with normal support; (3) periodontal
and who have been and are able to maintain their dentition disease stability, characterized as a state in which the
without signs of clinical gingival inflammation.11 According to periodontitis has been successfully treated and clinical signs
the WHO health framework,29 the absence of inflammatory of the disease do not appear to worsen in extent or severity
periodontal disease allows an individual to function normally despite the presence of a reduced periodontium; and (4)
and avoid the consequences (mental or physical) associated to periodontal disease remission/control, characterized as a period
present or past disease.11 in the course of disease when symptoms become less severe
Assessing periodontal health is important to establish a but may not be fully resolved with a reduced periodontium
common reference point for diagnosing disease and determining (Table 2). 6,21 It should be noted that “pristine periodontal
Table 2. CLASSIFICATION GINGIVAL HEALTH AND GINGIVAL DISEASE AND CONDITIONS ( Adapted from Chapple et al. 11 )
Periodontal Diseases and Conditions
Periodontal Health Gingivitis—Dental Gingival Disease—Non-dental

1. Clinical health on an intact Plaque-induced Plaque-induced
periodontium 1. Associated with biofilm alone 1. Genetic/developmental disorders (e.g.,
2. Clinical gingival health on 2. Mediated by systemic or local risk hereditary gingival fibromatosis)
a reduced periodontium factors 2. Specific infections
a. Stable periodontitis patient a. Systemic risk factors (modifying a. Bacterial origin
b. Non-periodontitis patient factors) b. Viral origin
– Smoking c. Fungal origin
3. Inflammatory and immune conditions
– Hyperglycemia
a. Hypersensitivity reactions
– Nutritional factors b. Autoimmune diseases of skin
– Pharmacological agents and mucous membranes
(prescription, non-prescription, c. Granulomatous inflammatory lesions
and recreational) (e.g., orofacial granulomatosis)
– Sex steroid hormones (puberty, 4. Reactive processes (e.g., epulides)
menstrual cycle, pregnancy, 5. Neoplasms
and oral contraceptives) a. Premalignancy
– Hematological conditions b. Malignancy
b. Local risk factors (predisposing 6. Endocrine, nutritional and metabolic
factors) diseases (e.g., vitamin deficiencies)
7. Traumatic lesions
– Dental plaque biofilm retention
factors (e.g., prominent a. Physical/mechanical trauma
restoration margins) b. Chemical (toxic) burn
– Oral dryness c. Thermal insults
8. Gingival pigmentation
3. Drug-influenced gingival enlargement
a. Melanoplakia
b. Smoker’s melanosis
c. Drug-induced pigmentation
(antimalarials, minocycline)
d. Amalgam tattoo

health” characterized by no attachment loss, no bleeding on (<10 percent in BoP sites), optimal therapeutic response (no
probing (BoP), no sulcular probing >3 millimeters (mm) probing depths >4 mm), and lack of progressive periodontal
in the permanent dentition and no redness, clinical swelling/ destruction while controlling for risk factors. Remission/
edema or pusis a rare entity, especially among adults.21 There- control is characterized by a significant decrease in inflam-
fore, minimal levels of clinical inflammation observed in mation, some improvement in other clinical parameters, and
“clinical periodontal health” is compatible with a patient stabilization of disease progression. Stability is the major
classified as periodontally healthy. treatment goal for periodontitis; however, remission/control
Monitoring gingival health or inflammation is best docu- may be the more realistically achievable therapeutic goal when
mented by the parameter of BoP since it is considered the it is not possible to fully control for modifying factors.11,19,22,28
primary parameter to set thresholds for gingivitis and the most There are three major determinants of clinical periodontal
reliable for monitoring patients longitudinally in clinical health. These include:
practice.6,21 Clinicians are encouraged to start probing regularly 1. microbiological determinants
when the first permanent molars are fully erupted and the a. supragingival plaque; and
child is able to cooperate for this procedure in order to establish b. subgingival biofilm compositions.
a baseline, detect early signs of periodontal disease, and prevent 2. host determinants
its progression. Probing prior to the eruption of the first a. local predisposing factors
permanent molars is encouraged in the presence or suspicion i. periodontal pockets;
of any clinical and/or radiographic signs of periodontal disease. ii. dental restorations;
While probing, clinicians should rule out the presence of iii. root anatomy;
pseudo pockets associated, for example, with tooth exfoliation iv. tooth position; and
or partially erupted teeth. For patients with special health v. crowding.
care needs receiving dental treatment under sedation and/or b. systemic modifying factors
general anesthesia, clinicians are encouraged to take this op- i. host immune function;
portunity and perform the periodontal probing. The probing ii. systemic health; and
force should not exceed 0.25 Newton (light probing) in or- iii. genetics.
der to rule out the confounding issue of BoP induced by too 3. environment determinants
much pressure, as well as unnecessary bleeding resulting from a. smoking;
trauma.21 When probing positioning and pressure into the b. medications;
sulcus/pocket are performed correctly, the patient should not c. stress; and
feel discomfort. With regards to periodontal probing depth d. nutrition.
(PPD), there is strong evidence that deep pockets are not
necessarily consistent with disease. Deep pockets may remain In order to attain or maintain clinical periodontal health,
stable and uninflamed, especially in cases where patients receive clinicians should not underestimate predisposing and modify-
long term careful supportive periodontal care and are referred ing factors for each patient and should recognize when these
to as “healthy pockets”. PPD or probing attachment levels factors can be fully controlled or not. Predisposing factors are
alone should not be used as evidence of gingival health or any agent or condition that contributes to the accumulation of
disease; rather, they should be considered in conjunction with dental plaque (e.g., tooth anatomy, tooth position, restorations),
other important clinical parameters such as BoP, as well as while modifying factors are any agent or condition that alters
modifying and predisposing factors. Radiographic assessment the way in which an individual responds to subgingival plaque
is a critical component of clinical assessment of the periodontal accumulation (e.g., smoking, systemic conditions, medications).
tissues. Radiographically, a normal, anatomically-intact perio- Many factors are determined controllable (e.g., removal of
dontium would present an intact lamina dura, no evidence of overhangs, smoking cessation, good diabetes control) while
bone loss in furcation areas, and a two mm distance (on others are not (e.g., genetics, immune status, use of critical
average, varying between 1.0 and 3.0 mm) from the most medications).21
coronal portion of the alveolar bone crest to the cemento-
enamel junction. While analyzing dental radiographs of Gingival health
children, it is important that clinicians not follow only on Gingival health (GH) is usually associated with an inflammatory
diagnosing interproximal carious lesions, but also evaluate infiltrate and host response in relatively stable equilibrium.21
the periodontal status, especially as the child grows older. GH in a patient with intact periodontium is diagnosed by (1)
Tooth mobility is not recommended as a clinical parameter of no probing attachment loss, (2) no radiographic bone loss
either periodontal health or disease status.21 (RBL), (3) <3 mm of PPD, and (4) <10 percent BoP.11 GH can
Important main differences between periodontal disease be restored following treatment of gingivitis and periodontitis.
stability and periodontal disease remission/control are the The diagnostic criteria for GH in a patient following treatment
ability to control for any modifying factors and the therapeutic of gingivitis are the same as those just mentioned. These same
response. Stability is characterized by minimal inflammation clinical features also are observed on a reduced periodontium

following successful treatment of periodontitis. A patient with diagnostic criteria for gingivitis is based on clinical features.
a current GH status who has a history of successfully treated Radiographs and probing attachment level analysis should not
and stable periodontitis remains at an increased risk of recur- be used to diagnose gingivitis since they usually do not indicate
rent periodontitis; therefore, the patient should be monitored loss of supporting structures. Clinical signs of inflammation
closely to ensure optimal disease management. include erythema, edema, heat, and loss of function. Clinical
signs of gingivitis include swelling (loss of knife-edged gingival
Gingival diseases and conditions margin and blunting of papillae), redness, and bleeding and
Gingivitis is a reversible disease characterized by an inflamma- discomfort on gentle probing. Patient symptoms may include
tion of the gingiva that does not result in clinical attachment bleeding gums, metallic/altered taste, pain/soreness, halitosis,
loss (CAL).30 Gingivitis is highly prevalent among children difficulty eating, appearance of swollen red gums, and reduced
and adolescents11,21 and a necessary prerequisite for the de- oral health-related quality of life. 11Although there are no
velopment of periodontitis and progressive connective tissue objective clinical criteria for defining gingivitis severity, the
attachment and bone loss.6,22,28 Controlling gingival inflam- extent of gingivitis (referred as mild, moderate, and severe)
mation is considered the primary preventive strategy for can be used as a patient communication tool. The definitions
periodontitis, as well as the secondary preventive strategy for of mild, moderate, and severe gingivitis continue to be a
recurrence of periodontitis. Even though there is a predilection matter of professional opinion. Practitioners may define gin-
of attachment loss to occur at inflamed sites of the gingiva, givitis as percentages of BoP sites (e.g., mild = <10 percent,
not all affected areas are destined to progress to periodontitis. moderate = 10-30 percent, severe = >30 percent sites) or based
This is because the inter-relationship between health, gingivitis, on grading (e.g., grade 1 to 5 in 20 percent quintiles for
and periodontitis is highly dependent on the host’s susceptibility percent sites BoP).10 The gingival index by Löe31 also can be
and immune-inflammatory response. Nevertheless, clinicians used to describe intensity of gingival inflammation as mild
must understand their crucial role in ongoing management of
gingivitis for their patients of all ages with and/or without a Table 3. DIAGNOSTIC LOOK-UP TABLE FOR GINGIVAL HEALTH
history of periodontal disease. There are broadly two categories OR DENTAL PLAQUE-INDUCED GINGIVITIS IN
of gingival disease and conditions: dental plaque biofilm- CLINICAL PRACTICE ( Adapted from Chapple et al. 11 )
induced gingivitis and non-dental plaque-induced gingival
disease. Intact periodontium Health Gingivitis
Probing attachment loss No No
Dental plaque biofilm-induced gingivitis
Probing pocket depths
During the 2017 World Workshop on the Classification of ≤3 mm ≤3 mm
(assuming no pseudo pockets)
Periodontal and Peri-implant Diseases and Conditions, revisions Bleeding on probing <10% Yes (≥10%)
of the 1999 classification system5 for dental plaque-induced
Radiological bone loss No No
gingival diseases included four components: (1) description of
the extent and severity of the gingival inflammation; (2) Reduced periodontium Health Gingivitis
description of the extent and severity of gingival enlargements; Non-periodontitis patient
(3) a reduction in gingival disease taxonomy; and (4) discus-
Probing attachment loss Yes Yes
sion of whether mild localized gingivitis should be considered
Probing pocket depths (all sites
a disease or variant of health.22 These four components are ≤3 mm ≤3 mm
& assuming no pseudo pockets)
addressed in this review.
Dental plaque biofilm-induced gingivitis usually is regarded Bleeding on probing <10% Yes (≥10%)
as a localized inflammation initiated by microbial biofilm Radiological bone loss Possible Possible
accumulation on teeth and considered one of the most com-
Successfully treated stable Health Gingivitis in a
mon human inflammatory diseases (Table 2).6,19 When dental periodontitis patient patient with
plaque is not removed, gingivitis may initiate as a result of loss a history of
of symbiosis between the biofilm and the host’s immune- periodontitis
inflammatory response. The common features of plaque-induced
Probing attachment loss Yes Yes
gingivitis include (1) clinical signs and symptoms of inflamma-
tion confined to the free and attached gingiva that do not ≤4 mm
Probing pocket depths (all sites
(no site ≥4 mm ≤3 mm
extend to the periodontal attachment (cementum, periodontal & assuming no pseudo pockets)
with BoP)
ligament and alveolar bone); (2) reversibility of the inflam-
Bleeding on probing <10% Yes (≥10%)
mation achieved by biofilm removal at and apical to the
gingiva margin; (3) presence of a high bacterial plaque burden Radiological bone loss Yes Yes
needed to initiate the inflammation; and (4) stable attachment
© 2018 American Academy of Periodontol and European Federation of Periodontology.
levels on a periodontium, which may or may not have experi- J Periodontol 2018;89(Supp 1):S74-S84. John Wiley and Sons.
enced a loss of attachment or alveolar bone (Table 3).11,22,28 The Available at: “https://aap.onlinelibrary.wiley.com/doi/full/10.1002/JPER.17-0719”.

(area with a minor change in color and little change in the crowding, and eruption of teeth. As for the use of oral contra-
texture of the tissue), moderate (area with glazing, redness, ceptives, exaggerated gingival inflammatory response to
edema, enlargement, and bleeding upon probing), and severe plaque is not reported in current, lower-dosage formulations as
(area of overt redness and edema with a tendency toward previously was observed with first generation high-dose oral
bleeding when touched rather than probed). Lastly, the extent contraceptives.32-34 Although modest gingival inflammation
or the number of gingival sites exhibiting gingival inflam- changes have been reported during ovulation,35-37 most women
mation can be described as either localized (<30 percent of with gingival inflammation associated with menstrual cycles will
the teeth are affected) or generalized (≥30 percent of the teeth present with non-detectable clinical signs of the condition.38-40
are affected).22 Hyperglycemia, hematologic malignancies (e.g., leukemia),
As mentioned above, one revision from the 1999 classification and nutritional deficiencies also are significant systemic condi-
system 5 was the proposal to introduce the term incipient tions that can negatively affect the gingival tissues. Increased
gingivitis “where, by definition, only a few sites are affected by incidence of chronic gingivitis and risk of periodontitis among
mild inflammation, expressed as mild redness and/or a delayed children with poorly controlled type 1 diabetes mellitus have
and broken line of bleeding rather than edema or an imme- been reported.41-43 The severity of gingival inflammation may
diate unbroken line of bleeding on probing. Incipient gingivitis be more associated with the level of glycemic control rather
may be regarded as a condition that is part of a spectrum of than the quality of plaque control.36-40 Hyperglycemia can alter
‘clinical health,’ but may rapidly become localized gingivitis the immune system and have a negative direct effect on perio-
if untreated.”22 dontal cells and neutrophil activity, as well as have an indirect
The severity, extent, and progression of plaque-induced adverse effect by stimulating immune system cells to release
gingivitis at specific sites or at the entire mouth vary between inflammatory cytokines.44,45 Early diagnosis of periodontal prob-
individuals and can be influenced by local (predisposing) and lems among children and adolescents with poorly controlled
systemic (modifying) factors. Local oral factors that exacerbate diabetes through periodic periodontal screenings, as well as
plaque-induced gingivitis are those that can influence the ini- prevention of periodontal diseases among this population, is
tiation or progression of gingival inflammation by facilitating of fundamental importance. It is worth mentioning that, in
accumulation of bacterial plaque at a specific site, inhibiting addition to gingivitis and periodontitis, xerostomia and candida
daily mechanical plaque removal, and/or creating a biological infections also are associated with diabetes.45 Certain hemato-
niche that encourages increased plaque accumulation. Examples logic malignancies (e.g., leukemia) are associated with signs of
of plaque-induced gingivitis exacerbated by plaque biofilm excess gingival inflammation inconsistent with levels of dental
retention are prominent subgingival restoration margins and plaque biofilm accumulation. Oral manifestations include
certain tooth anatomies that contribute with plaque accu- gingival enlargement/bleeding, petechiae, oral ulcerations/
mulation increasing the risk for gingivitis and, consequently, infections, and cervical lymphadenopathy. Signs of gingival
compromising the gingival health. Oral dryness is a clinical inflammation include swollen, glazed, and spongy tissues that
condition frequently associated with xerostomia, which in turn are red to deep purple in appearance.11,22,46,47 These oral mani-
is a symptom caused by a decrease in the salivary flow (hypo- festations may be either the result of direct gingiva infiltration
salivation). Hyposalivation interferes with plaque removal, of leukemic cells or thrombocytopenia and/or clotting-factor
thereby increasing the risk of caries, halitosis, and gingival deficiencies. Both gingival bleeding and hyperplasia have been
inflammation among other oral conditions. Xerostomia may reported as initial oral signs and symptoms of patients with acute
occur as a side effect of medications such as antidepressants, and chronic leukemias.22,46,47 Through periodic clinical examina-
antihistamines, decongestants, and antihypertensive medications, dentists have an opportunity for early diagnosis of such
tions. In addition, health diseases/conditions such as Sjögren’s malignant diseases, as well as timely referral and, subsequently,
syndrome, anxiety, and poorly controlled diabetes may cause increased chances for improved patient treatment outcomes.
xerostomia due to hyposalivation.11,22 The literature lacks information regarding the exact role of
Systemic risk factors can modify the host immune inflam- nutrition in the initiation and/or progression of periodontal
matory response in the presence of dental plaque biofilm diseases. However, the role of vitamin C (ascorbic acid) in
resulting in exaggerated inflammatory response. Examples supporting periodontal tissues due to its essential function in
of systemic conditions include: (1) sex steroid hormones collagen synthesis is well-documented.10,19 Vitamin C deficiency,
(e.g., puberty, pregnancy, menstrual cycle, oral contraceptives); or scurvy, compromises antioxidant micronutrient defenses
(2) hyperglycemia; (3) leukemia; (4) malnutrition; and (5) to oxidative stress and collagen synthesis leading to weakened
smoking.11,22 capillary blood vessels, consequently increasing the predis-
Elevations in sex steroid hormones, especially, during position to gingival bleeding.48 Nevertheless, gingival inflam-
puberty and pregnancy may modify the gingival inflammatory mation due to vitamin C deficiency may be difficult to detect
response and result in an exaggerated gingival inflammation clinically and indistinguishable from plaque-induced gingivitis.22
in the presence of even relatively small amounts of plaque. Scurvy may occur in certain populations of pediatric interest
Other factors that predispose to gingivitis in both male and such as infants and children from low socioeconomic families.22
female adolescents are dental caries, mouth breathing, dental

One major change in the 2017 classification of dental throughout the mouth).22 Mild gingival enlargement involves
plaque-induced gingival diseases was to simplify the system for enlargement of the gingival papilla; moderate gingival enlarge-
the clinician and condense the catalog to include only condi- ment involves enlargement of the gingival papilla and marginal
tions affecting the gingiva that could be clinically identified. gingiva; and severe gingival enlargement involves enlargement
Therefore, terms previously used such as menstrual cycle- of the gingival papilla, gingival margin, and attached gingiva.22
associated gingivitis, oral contraceptive–associated gingivitis, Drug-influenced gingival enlargement is not associated with
and ascorbic acid-associated gingivitis were eliminated from attachment loss or tooth mortality.
the classification system because signs of these conditions were
not clinically evident to the dentist.11 Non-dental plaque-induced gingival diseases
Smoking is a major lifestyle and behavioral risk factor for The gingiva and oral tissues may demonstrate a variety of
periodontitis mostly attributed to alterations in the microflora gingival lesions that are not caused by plaque and usually do
and/or host response. 11,22 Increased pocket depth measure- not resolve after plaque removal (Table 2). 6 However, the
ments, attachment loss, and alveolar bone loss are more prevalent severity of the clinical manifestations of these lesions often
in smokers than non-smokers. 49 Tobacco use is no longer is dependent upon plaque accumulation and subsequent gin-
classified as a habit but as a dependence to nicotine and a gival inflammation. These lesions may be manifestations of a
chronic relapsing medical disorder.50 Smoking and smokeless systemic condition or medical disorder. They also may represent
tobacco use almost always are initiated and established in pathologic changes confined to the gingiva. Because oral health
adolescence. 51-57 The most common tobacco products used and systemic health are strongly interrelated, it is important
by middle school and high school students are reported to that dentists and other health care providers collaborate to
be e-cigarettes, cigarettes, cigars, smokeless tobacco, hookahs, adequately diagnose, educate the patient about his condition,
pipe tobacco, and bidis (unfiltered cigarettes from India). 52 treatment plan, treat, or refer to a specialist for treatment. The
However, the exposure to cannabis (marijuana) among chil- current classification of non-dental plaque-induced gingival
dren and adolescents has increased in the United States due conditions is based on the etiology of the lesions. These in-
to its legalization in many states.55 Frequent cannabis use has clude: genetic/developmental disorders (e.g., hereditary gingival
been associated with deeper probing depths, more CAL, and fibromatosis); specific infections of bacterial (e.g., necrotizing
increased risk of severe periodontitis.55 Periodontitis, visible periodontal diseases, Streptococcal gingivitis), viral (e.g., hand-
plaque, and gingival bleeding also have been reported among foot-and-mouth disease, primary herpetic gingivostomatitis),
crack cocaine users. 56 Clinical signs associated with smoke- and fungal (e.g., candidiasis) origins; inflammatory and
less tobacco may include increased gingival recession and immune conditions and lesions (e.g., hypersensitivity reactions,
attachment loss, particularly at the sites adjacent to mucosal autoimmune disease of skin and mucous membranes); reactive
lesion associated with the habit. 55 Health professionals who processes (e.g., epulides); premalignant neoplasms (e.g., leuko-
treat adolescents and young adults should be aware of the plakia); malignant neoplasms (e.g., leukemia, lymphoma);
signs of tobacco use and be able to provide counseling (or traumatic lesions (e.g., physical, chemical, thermal insults);
referral to an appropriate provider) regarding the serious endocrine, nutritional, and metabolic diseases (e.g., vitamin
health consequences of tobacco and drug use, as well as use deficiencies); and gingival pigmentation (e.g., amalgam tattoo).
brief interventions for encouragement, support, and positive The major difference between the 1999 and 2017 classifications
reinforcement for cessation when the habit is identified. is the development of a more comprehensive nomenclature
Drug-influenced gingival enlargements occur as a side effect of non-plaque induced gingival diseases and conditions based
in patients treated with anticonvulsant drugs (e.g., phenytoin, on the primary etiology, as well as the inclusion of the Interna-
sodium valproate), certain calcium channel–blocking drugs tional Statistical Classification of Diseases and Related Health
(e.g., nifedipine, verapamil, diltiazem, amlodipine, felodipine), Problems (ICD)–10 diagnostic codes (e.g., ICD–10 code for
immune-regulating drugs (e.g., cyclosporine), and high-dose primary herpetic gingivostomatitis is B00.2).6,11,19 Several of
oral contraceptives.11,57 For drug-influenced gingival conditions these conditions may occur in pediatric patients, as well as in
to occur, the presence of plaque bacteria is needed. The onset those with special health care needs; therefore, they are of great
of this condition may occur within three months of the drug interest to pediatric dentists. For a comprehensive review on
use, 11 but not all individuals taking these medications are this topic, the reader is encouraged to review the position paper
susceptible and will develop gingival overgrowth. Reports show on non-dental plaque-induced gingival diseases by Holmstrup
that approximately half of the people who take phenytoin, et al.19 and the workshop consensus report by Chapple et al.11
nifedipine, or cyclosporin are affected with this condition.57 A
major consideration during the 2017 workshop was to select Classification of periodontal diseases
an easy and appropriate clinical assessment to define the extent The new classification of periodontal disease proposed in the
and severity of the drug-influenced overgrowth. The extent of 2017 workshop defines three distinct forms: (1) periodontitis
gingival enlargements was defined as either localized (enlarge- (single category grouping the two forms of the disease
ment limited to the gingiva in relation to a single tooth or formerly recognized as aggressive or chronic); (2) necrotizing
group of teeth) or generalized (enlargement involves the gingiva periodontitis; and (3) periodontitis as a manifestation of systemic

conditions. The new periodontitis classification was further pseudomembrane formation, and halitosis.18,24 In severe cases,
characterized based on a multi-dimensional staging and grading bone sequestrum also may occur. 58 Pain and halitosis are
framework system. The former indicates the disease severity observed less often among children, while systemic conditions
and complex management, while the latter estimates the rate such as fever, adenopathy, and sialorrhea (hypersalivation) are
and likelihood of the disease progression and/or response to observed more frequently.18,59 Necrotizing periodontal diseases
standard periodontal therapy taking into consideration the are strongly associated with impairment of the host immune
patient’s biological features.6,24,26 An individual case of perio- system. Predisposing factors include inadequate oral hygiene,
dontitis should be further defined using a simple matrix that chronic gingivitis, human immunodeficiency virus and
describes the stage and grade of the disease24 as seen in Table 4. acquired immune deficiency syndrome (HIV/AIDS), malnu-
trition, tobacco/alcohol consumption, psychological stress,
Periodontitis and insufficient sleep among others.24 Among children, higher
Currently, evidence is insufficient to support the notion that risk of necrotizing periodontitis is observed in those with se-
chronic and aggressive periodontitis are two pathophysiologically vere malnutrition, extreme living conditions (e.g., substandard
distinct diseases. Due to concerns from clinicians, researchers, accommodations, limited access to potable water, poor sanitary
educators, and epidemiologists regarding their ability to prop- disposal system), and disease resultant from severe viral infec-
erly distinguish between chronic and aggressive periodontitis, tions (e.g., HIV/AIDS, measles, chicken pox, malaria).18,24
the 2017 World Workshop members proposed grouping these Although the prevalence of necrotizing periodontitis is low, it
two previously forms of periodontitis into a single category is a severe condition leading to very rapid tissue destruction
simply referred to as periodontitis.24,27 The clinical entity pre- that can be life-threating among compromised children.18 For
viously referred to as aggressive periodontitis due to its rapid a more in-depth review of necrotizing periodontitis, readers
rate of progression is now categorized as Grade C periodontitis are directed to the positional papers by Herrera et al. 18 and
and represents the extreme end of a continuum of disease rates. Tonetti et al.,27 as well as to the consensus report by Papapanou
Periodontitis is a multifactorial, microbially-associated, et al.24
host-mediated inflammatory disease characterized by progres- Systemic disease is defined as a disease that affects multiple
sive destruction of the periodontal attachment apparatus. Loss organs and tissues or that affects the body as a whole.60 Several
of periodontal tissue support is the primary feature of perio- systemic disorders and conditions can affect the course of
dontitis, which is detected as CAL by circumferential assessment periodontal diseases or have a negative impact on the periodontal
of erupted teeth using a standardized periodontal probe with attachment apparatus independently of dental biofilm-induced
reference to the cemento-enamel junction. Clinically, a patient inflammation.7,20 For some cases, the periodontal problems may
is characterized as a periodontitis case if: (1) interdental CAL be among the first signs of the disease. These disorders or
is detectable at ≥2 non-adjacent teeth; or (2) buccal or oral conditions are grouped as periodontitis as a manifestation of
CAL ≥3 mm with pocketing >3 mm is detectable at ≥2 teeth. systemic disease, and classification should be based on and fol-
Furthermore, the CAL cannot be attributed to non-periodontal low the classification of the primary systemic disease according
causes such as: (1) gingival recession of traumatic origin; (2) to the respective ICD codes.6 Moreover, they can be grouped
dental caries extending in the cervical area of the tooth; (3) the into broad categories such as genetic disorders that affect the
presence of CAL on the distal aspect of a second molar and host immune response (e.g., Down syndrome, Papillon-Lefèvre,
associated with malposition or extraction of a third molar; (4) histiocytosis) or affect the connective tissues (e.g., Ehlers-
an endodontic lesion draining through the marginal perio- Danlos syndrome, systemic lupus erythematosus); metabolic
dontium; and (5) the occurrence of a vertical root fracture.24,27 and endocrine disorders (e.g., hypophosphatasia, hypophos-
In the context of the 2017 World Workshop, three clearly phatemic rickets); inflammatory conditions (e.g., epidermolysis
different forms of periodontitis have been identified based on bullosa acquisita, inflammatory bowel disease); as well as
pathophysiology. Differential diagnosis is based on the history other systemic disorders (e.g., obesity, emotional stress and
and the specific signs and symptoms of necrotizing periodon- depression, diabetes mellitus, Langerhans cell histiocytosis,
titis and the presence or absence of an uncommon systemic neoplasms). For a more comprehensive review of classifications,
disease that definitively modify the host immune response.6,24,27 case definitions and diagnostic considerations, the reader is
Evidence supports necrotizing periodontitis as a separate encouraged to read the positional paper and consensus report
disease entity based on (1) distinct pathophysiology charac- by Albandar et al.7 and Jepsen et al.,20 respectively.
terized by prominent bacterial invasion and ulceration of The remaining clinical cases of periodontitis that do not
epithelium; (2) rapid and full thickness destruction of the present with the local characteristics of necrotizing periodontitis
marginal soft tissue resulting in characteristic soft and hard or the systemic characteristics of a rare immune disorder with a
tissue defects; (3) obvious symptoms; and (4) faster resolution secondary manifestation of periodontitis should be diagnosed
in response to specific antimicrobial treatment.27 This painful as periodontitis and be further characterized using the staging
and infectious condition should be diagnosed primarily based and grading system that describes clinical presentation,6,7,18,20,24,27
on its typical clinical features, which includes necrosis and (Table 4).
ulceration in the interdental papilla, gingival bleeding,

The concept of staging is adopted from the field of oncol- periodontal infections, pericoronitis, trauma, surgery, or foreign
ogy that classifies staging of tumors based on baseline clinical body impaction may explain the development of PA. PA can
observations of size or extent and whether it has metastasized develop in both periodontitis and non-periodontitis patients.
or not.61 Understanding the stage of the periodontal disease Of interest to pediatric dentists, PA can occur in healthy
helps the clinician communicate with the patient the current sites due to impaction of foreign bodies (e.g., dental floss,
severity and extent of the disease (localized or generalized), orthodontic elastic, popcorn hulls), harmful habits (e.g., nail
assess the complexities of disease management, develop a biting, clenching), inadequate orthodontic forces, gingival en-
prognosis, and design an individualized treatment plan for the largement, and alterations of the root surface (e.g., invaginated
patient. Staging is determined by a number of variables such tooth, alterations, enamel pearls, iatrogenic perforations, vertical
as PPD, CAL, amount and percentage of bone loss, presence root fracture, external root resorption).
and extent of angular bony defects and furcation involvement, EPL are pathological communications between the endo-
tooth mobility, and tooth loss due to periodontitis.27 Staging dontic and periodontal tissues at a given tooth that occur in
involves four categories: Stage I (initial periodontitis), Stage II either an acute or a chronic form and are classified according
(moderate periodontitis), Stage III (severe periodontitis – to the signs and symptoms that have direct impact on their
potential for tooth loss), and Stage IV (advanced periodontitis – prognosis and treatment (e.g., presence or absence of fractures
potential for loss of dentition). Grading assesses the future risk and perforations, presence or absence of periodontitis and the
of the periodontitis progression and anticipated treatment extent of periodontal destruction around the affected teeth).
outcomes but also estimates the positive or negative impact The primary signs associated with EPL are deep periodontal
that periodontitis and its treatment have on the overall health pockets reaching or close to the apex and/or negative or altered
status of the patient. Grading also allows the clinician to response to pulp vitality tests. Other signs and symptoms may
incorporate the individual patient risk factors (e.g., smoking, include radiographic evidence of bone loss in the apical or
uncontrolled Type 2 diabetes) into the diagnosis, which may furcation region, spontaneous pain or pain on palpation and
influence the comprehensive case management. Grading percussion, purulent exudate or suppuration, tooth mobility,
includes three levels: Grade A (low risk of progression), Grade sinus tract/fistula, and crown and/or gingival color altera-
B (moderate risk of progression), and Grade C (high risk of tions.18,24 Signs observed in EPL associated with traumatic
progression). Table 4 shows the framework for staging and and/or iatrogenic factors may include root perforation, fracture/
grading of periodontitis, as well as the criteria for periodontitis cracking, or external root resorption, commonly associated
stage and grade, respectively.27 Table 5 presents the three steps with the presence of an abscess accompanied by pain. In
to staging and grading a patient with periodontitis. 27 For a periodontitis patients, EPL usually presents low and chronic
more comprehensive description of staging and grading of progression without evident symptoms. For further review on
periodontitis, the reader is encouraged to review an outcome the classification, pathophysiology, microbiology, and histo-
workshop paper by Tonetti et al.27 and the workshop consensus pathology of both PA and EPL, readers are directed to the
report by Papapanou et al.24 positional paper by Herrera et al.18 and the consensus report by
Papapanou et al.24
Other conditions affecting the periodontium
Peridontal abscesses and endodontic-periodontal lesions Mucogingival deformities and conditions
Both periodontal abscesses (PA) and endodontic-periodontal Normal mucogingival condition is defined as the absence of
lesions (EPL) share similar characteristics that differentiate pathosis such as gingival recession, gingivitis, and periodon-
them from other periodontal conditions. These include pain titis. Mucogingival deformities, including gingival recession,
and discomfort requiring immediate emergency treatment, are a group of conditions that affect a large number of pa-
rapid onset and destruction of periodontal tissues, negative tients, are observed more frequently in adults, and have a
effect on the prognosis of the affected tooth, and possible severe tendency to increase with age independent of the patient/s
systemic consequences. oral hygiene status. Recession is defined as an apical shift of
PA are defined as acute lesions characterized by localized the gingival margin caused by different conditions and
accumulation of pus within the gingival wall of the perio- pathologies that is associated with CAL in any surface (buccal/
dontal pocket, initiated by either bacterial invasion or foreign lingual/interproximal) of the teeth. 20 Although, gingival
body impaction.18,24 The most prominent sign associated with thickness has been referenced in the literature as gingival
PA is the presence of an ovoid elevation in the gingiva along biotype, the 2017 World Workshop group strongly suggested
the lateral part of the root. Other signs and symptoms may the adoption of the term periodontal phenotype, which is
include pain, tenderness and swelling of the gingiva, bleeding determined by gingival phenotype (gingival thickness,
and suppuration on probing, deep periodontal pocket, bone keratinized tissue width) and bone morphotype (thickness of
loss observed radiographically, and increased tooth mobility.18,24 the buccal bone plate). Periodontal phenotype can be assessed
Facial swelling, elevated body temperature, malaise, regional by measuring the gingival thickness through the use of a
lymphadenopathy, or increased blood leukocytes are less periodontal probe. The phenotype is classified as thin when a
commonly observed.18 Etiologic factors such as pulp necrosis, periodontal probe inserted into the sulcus is visible through

Table 4. PERIODONTITIS STAGING AND GRADING ( Adapted from Tonetti et al.27 )
Disease Severity and Complexity of Management
Framework for periodontitis Stage I: Stage II: Stage III: Stage IV:
staging and grading Initial Moderate Severe periodontitis with Advanced periodontitis with extensive
periodontitis periodontitis potential for additional tooth loss and potential for loss of
tooth loss dentition
Evidence or risk of rapid Grade A

progression, anticipated
treatment response, and Grade B Individual Stage and Grade Assignment
effects on systemic health Grade C
Periodontitis stage Stage I Stage II Stage III Stage IV
Interdental 1 to 2 mm 3 to 4 mm ≥5 mm ≥5 mm
CAL at site
of greatest loss
Radiographic Coronal third Coronal third Extending to mid-third Extending to mid-third of root
Severity
bone loss (<15%) (<15% to 33%) of root and beyond and beyond
Tooth loss No tooth loss due to periodontitis Tooth loss due to Tooth loss due to periodontitis
periodontitis of ≤4 teeth of ≥5 teeth
Local Maximum Maximum probing In addition to stage II In addition to stage III complexity:
probing depth depth ≤5 mm complexity: Need for complex rehabilitation due to:
≤4 mm – Masticatory dysfunction
Mostly horizontal – Probing depth ≥6 mm
Mostly bone loss – Secondary occlusal trauma
– Vertical bone loss ≤3 mm
Complexity horizontal (tooth mobility degree ≥2)
– Furcation involvement – Severe ridge defect
bone loss
Class II or III – Bite collapse, drifting, flaring
– Moderate ridge defect – Less than 20 remaining teeth
(10 opposing pairs)
Extent and Add to stage

distribution as descriptor For each stage, describe extent as localized (<30% of teeth involved), generalized, or molar/incisor pattern
Grade A: Grade B: Grade C:

Periodontitis grade Slow rate of Moderate rate of Rapid rate of progression
progression progression
Direct evidence Longitudinal data Evidence of no loss <2 mm over 5 years ≥2 mm over 5 years
of progression (RBL or CAL) over 5 years
Indirect evidence % bone loss/age <0.25 0.25 to 1.0 >1.0

of progression
Primary Case phenotype Heavy biofilm Destruction Destruction exceeds expectation given
criteria deposits with low commensurate with biofilm deposits; specific clinical patterns
levels of destruction biofilm deposits suggestive of periods of rapid progression
and/or early onset disease (e.g., molar/
incisor pattern; lack of expected response
to standard bacterial control therapies)
Risk factors Smoking Non-smoker Smoker <10 Smoker ≥10 cigarettes/day

cigarettes/day
Grade
modifiers Diabetes Normoglycemic/no HbAlc <7.0% in HbAlc ≥7.0% in patients with diabetes
diagnosis of diabetes patients with diabetes

the tissue, indicating the tissue is 1 mm thick. If the probe is There is either little or no evidence that traumatic occlusal
not visible through the tissue, indicating the tissue is >1mm forces can cause periodontal attachment loss, inflammation
thick, it is classified as a thick phenotype.20 The development of the periodontal ligament, non-carious cervical lesions,
and progression of gingival recession is not associated with abfraction, or gingival recession.14,20 Traumatic occlusal forces
increased tooth mortality. However, this condition often is lead to adaptive mobility in teeth with normal support and
associated with patient esthetic concerns, dentinal hypersensi- are not progressive, while in teeth with reduced support,
tivity and carious/non-carious cervical lesions on the exposed they lead to progressive mobility usually requiring splinting.
root surface.12,20 While lack of keratinized tissue is a Although, there is evidence that traumatic occlusal forces may
predisposing factor for gingival recession and inflammation, be associated periodontitis, there is no evidence that these forces
periodontal health can be maintained despite
the lack of keratinized tissues in most patients Table 5. THREE STEPS TO STAGING AND GRADING A PATIENT WITH PERIODONTITIS
with optimal home care and professional ( Adapted from Tonetti et al. 27 )
maintenance. Conversely, patients with thin
periodontal phenotypes, with inadequate
oral hygiene, and requiring cervical restorative Screen:
and/or orthodontic treatment are at an • Full mouth probing
increased risk for gingival recession.12,20 Step 1 • Full mouth radiographs
Monitoring specific gingival recession sites Initial Case • Missing teeth
is considered a proper approach in the absence Overview to Mild to moderate periodontitis will typically be either
of any pathosis. However, mucogingival Assess Disease Stage I or Stage II
surgical interventions may be necessary in the Severe to very severe periodontitis will typically be
presence of esthetic concerns, dentin hyper- either Stage III or g IV
sensitivity, cervical lesions, thin gingival
biotypes and mucogingival deformities.
For mild to moderate periodontitis (typically Stage I
Traumatic occlusal forces and occlusal trauma or Stage II):
Traumatic occlusal force is defined as “any • Confirm clinical attachment loss (CAL)
occlusal force that causes an injury to the teeth • Rule out non-periodontitis causes of CAL
and/or the periodontal attachment appara- (e.g., cervical restorations or caries, root fractures,
tus.”20 It may be indicated by one or more of CAL due to traumatic causes)
the following: fremitus (visible tooth move- • Determine maximum CAL or RBL
Step 2
ment upon occlusal force), tooth mobility, • Conform RBL patterns
Establish Stage
thermal sensitivity, excessive occlusal wear, For moderate to severe periodontitis (typically Stage III
tooth migration, discomfort/pain on chewing, or Stage IV):
fractured teeth, radiographically widened • Determine maximum CAL or RBL
periodontal ligament space, root resorption, • Confirm RBL patterns
and hypercementosis.20 Occlusal trauma is a • Assess tooth loss due to periodontitis
lesion in the periodontal ligament, cementum, • Evaluate case complexity factors (e.g., severe CAL
and adjacent bone caused by traumatic frequency, surgical challenges)
occlusal forces. It may be indicated by one
or more of the following: progressive tooth
mobility, fremitus, radiographically widened • Calculate RBL (% of root length x 100) divided
periodontal ligament space, tooth migration, by age
discomfort/pain on chewing, and root resorp- • Assess risk factors (e.g., smoking, diabetes)
tion.20 Traumatic occlusal forces and occlusal Step 3 • Measure response to scaling and root planning and
plaque control
trauma can be classified as: (1) primary occlusal Establish Grade
• Assess expected rate of bone loss
trauma; (2) secondary occlusal trauma; and
• Conduct detailed risk assessment
(3) orthodontic forces. Primary and secondary
• Account for medical and systemic inflammatory
occlusal trauma have been defined as injuries considerations
resulting in tissue changes from traumatic
occlusal forces, the former when applied to
a tooth or teeth with normal periodontal © 2018 American Academy of Periodontol and European Federation of Periodontology.
support and the latter when applied to a J Periodontol 2018;89(Supp 1):S159-S172. John Wiley and Sons.
tooth or teeth with reduced support.20 Available at: “https://aap.onlinelibrary.wiley.com/doi/full/10.1002/JPER.18-0006”.

can accelerate the progression of periodontitis in humans.20 or appliance. However, it appears that adequate periodontal
Moreover, there is insufficient clinical evidence regarding the assessment and treatment, appropriate instructions, and
impact that elimination of traumatic occlusal forces may have motivation in self-performed plaque control and compliance to
on the response to periodontal therapies. With regards to periodic maintenance protocols are the most important factors
orthodontic forces, observational studies suggest that ortho- to limit or avoid the potential negative effects on the perio-
dontic treatment has minimal adverse effects to the periodontal dontium caused by fixed and removable prostheses when
supporting apparatus, especially in patients with good plaque hypersensitivity reactions are not suspected.13
control and healthy periodontium. 14,20 However, non-
controlled orthodontic forces can have adverse effects such as Peri-implant diseases and conditions
pulpal disorders as well as root and alveolar bone resorptions. The 2017 World Workshop members developed a new clas-
sification for peri-implant health, peri-implant mucositis and
Dental prostheses and tooth-related factors peri-implantitis. The case definitions were developed based on
Several conditions associated with the fabrication and presence a review of the evidence applicable for diagnostic considera-
of dental restorations and fixed prostheses, placement of tions for use by clinicians for both individual case management
orthodontic appliances, as well as tooth-related factors may and population studies.6,25 Because the majority of pediatric
facilitate the development of gingivitis and periodontitis, dentists are not the ones responsible for the placement of
especially in individuals with poor compliance with home osseointegrated dental implants, the reader is encouraged to
care plaque control and attendance to periodic maintenance review the positional paper by Renvert et al. 25 and the con-
visits.13,20 sensus report by Berglundh et al.9 for more comprehensive
Tooth anatomic factors (e.g., cervical enamel projections, information about the rationale, criteria, and implementation
enamel pearls, developmental grooves), root proximity, abnor- of the new classification. Nevertheless, it is important that all
malities and traumatic dental injuries potentially altering the clinicians are able to diagnose potential problems, complica-
local anatomy of both hard and soft tissues, as well as tooth tions, and failures associated with dental implants in order to
relationships in the dental arch and with the opposing denti- either provide proper treatment or refer the patient to a spe-
tion, are associated with dental plaque-biofilm induced gin- cialist. Case definitions and clinical criteria of these conditions
givitis and periodontitis. Placement of restoration margins are presented below.
infringing within the junctional epithelium and supracrestal
connective tissue attachment (biological width) also can be Peri-implant health
associated with gingival inflammation and, potentially, Clinically, peri-implant health is characterized by an absence
recession. Tooth-supported and/or tooth-retained restorations of visual signs of inflammation such as redness, swelling, and
and their design, fabrication, delivery, and materials often have profuse BoP, as well as an absence of further additional bone
been associated with plaque retention and loss of periodontal loss following initial healing. Peri-implant health can occur
supporting tissues. However, optimal restoration margins around implants with normal or reduced bone support.6,25
located within the gingival sulcus do not cause gingivitis if
patients are compliant with self-performed plaque control and Peri-implant mucositis
periodic maintenance care.13,20 Peri-implant mucositis is characterized by visual signs of in-
The available evidence does not support that optimal flammation such as redness, swelling, and line or drop of
removable and fixed dental prostheses are associated with bleeding within 30 seconds following probing, combined
periodontitis when patients perform adequate plaque control with no additional bone loss following initial healing. There
and attend maintenance appointments. However, there is is strong evidence that peri-implant mucositis is caused by
evidence to suggest that removable dental prostheses can serve plaque, while very limited evidence for non-plaque induced
as plaque retentive factors and be associated with gingivitis/ peri-implant mucositis. Peri-implant mucositis can be reversed
periodontitis, increased mobility and gingival recession in with dental plaque removal measures.6,25
patients with poor compliance.20 Moreover, there is evidence
to suggest that design, fabrication, delivery, and materials used Peri-implantitis
for fixed dental prostheses procedures can be associated with Peri-implantitis is defined as a plaque-associated pathologic
plaque retention, gingival recession, and loss of supporting condition occurring in the tissue around dental implants, char-
periodontal tissues.13,20 acterized by signs of inflammation in the peri-implant mucosa,
Lastly, it is important to point out that dental materials, radiographic evidence of bone loss following initial healing,
including commonly used appliances (e.g., stainless steel increasing probing depth as compared to probing depth values
crowns, space maintainers, orthodontic appliances) may be after the implant placement, and subsequent progressive loss
associated with hypersensitivity reactions observed clinically of supporting bone. In the absence of baseline radiographs,
as localized inflammation. If the hypersensitivity does not radiographic bone level ≥3 mm in combination with BoP
resolve with adequate measures of plaque control, additional and probing depths ≥6 mm is indicative of peri-implantitis.
treatment may be required, including removal of material Peri-implantitis is preceded by peri-implant mucositis.6,25

Recommendations 2. Alrayyes S, Hart TC. Periodontal disease in children. Dis

1. Periodontal disease in children is of great interest in Mon 2011;57(4):184-91.
pediatric dentistry and a problem that should not be 3. Stenberg WV. Periodontal problems in children and
ignored. Therefore, it is critical that pediatric dental pa- adolescents. In: Nowak, AJ, Christensen JR, Mabry TR,
tients receive a periodontal assessment as part of their Townsend JA, Wells MH, eds. Pediatric Dentistry-Infancy
initial and periodic dental examinations. Early diagnosis through Adolescence, 6th ed. St. Louis, Mo.: Elsevier/
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2. Pediatric dentists are often the front line in diagnosing periodontal diseases and conditions. Ann Periodontol
periodontal conditions in children and adolescents and in 1999;4(11):1-6.
great position to treat or refer and coordinate, collaborate, 6. Caton JG, Armitage G, Berglundh T, et al. A new classifi-
and/or organize the patient care activities between two cation scheme for periodontal and peri-implant diseases
or more health care providers to ensure that the appro- and conditions–Introduction and key changes from the
priate treatment is delivered in a timely fashion. Therefore, 1999 classification. J Periodontol 2018;89(Suppl 1):
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Clinicians are encouraged to start probing regularly when diseases and conditions: Consensus report of workgroup
the first permanent molars are fully erupted and the 4 of the 2017 World Workshop on the Classification of
child is able to cooperate for this procedure in order Periodontal and Peri-Implant Diseases and Conditions. J
to establish a baseline, detect early signs of periodontal Clin Periodontol 2018;45(Suppl 20):S286-S291.
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4. Probing prior to the eruption of the first permanent Kocher T, Dye BA. Age-dependent distribution of perio-
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For patients with special health care needs receiving dental 2018;89(Suppl 1):S140-S158.
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The intent of this document was to present an abbreviated tion of Periodontal and Peri-Implant Diseases and
overview of the proceeding papers from the 2017 World Work- Conditions. J Periodontol 2018;89(Suppl 1):S74-S84.
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Dentistry. considerations. J Periodontol 2018;89(Suppl 1):
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BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY
Management Considerations for Pediatric Oral

Surgery and Oral Pathology
2020 considerations for pediatric oral surgery and oral pathology. The
Purpose Medical evaluation

The American Academy of Pediatric Dentistry (AAPD) Important considerations in treating a pediatric patient include
intends this document to define, describe clinical presentation, obtaining a thorough medical history, obtaining appropriate
and set forth general criteria and therapeutic goals for common medical and dental consultations, anticipating and preventing
pediatric oral surgery procedures and oral pathological emergency situations, and being prepared to treat emergency
conditions. situations.5
Methods Dental evaluation

Recommendations on management considerations for pediatric It is important to perform a thorough clinical and radiographic
oral surgery and oral pathology were developed by the preoperative evaluation of the dentition as well as a clinical
Council on Clinical Affairs and adopted in 2005.1 This examination of extraoral and intraoral soft tissues.5-7 Radio-
document is a revision of the previous version, last revised in graphs can include intraoral films and extraoral imaging if the
2015.2 It is based on a review of the current dental and med- area of interest extends beyond the dentoalveolar complex.
ical literature related to pediatric oral surgery, including a Surgery involving the maxilla and mandible of young patients
®
pediatric AND oral surgery, oral pathology, extraction,
is complicated by the presence of developing tooth follicles.
Knowledge of the anatomy of a child’s developing maxilla and
odontogenic infections, impacted canines, third molars, mandible and the avoidance of injury to the dental follicles
supernumerary teeth, mesiodens, mucocele, eruption cyst, can prevent complications.8 To minimize the negative effects
eruption hematoma, gingival keratin cysts, Epstein pearls, of surgery on the developing dentition, careful planning
Bohn’s nodules, congenital epulis of newborn, dental lamina using radiographs, tomography,9 cone beam computed tomo-
cysts, natal teeth, neonatal teeth, squamous papilloma, verruca graphy,10 and/or three-dimensional imaging techniques11 is
vulgaris, irritation fibroma, recurrent aphthous stomatitis, necessary to provide valuable information to assess the presence,
localized juvenile spongiotic gingival hyperplasia, and pyogenic absence, location, and/or quality of individual crown and root
granuloma; fields: all; limits: within the last 10 years, humans, development.8,12,13
English, clinical trials. Papers for review were chosen from
the list of articles matching these criteria and from references Growth and development
with selected articles. When data did not appear sufficient The potential for adverse effects on growth from injuries and/
or were inconclusive, recommendations were based upon or surgery in the oral and maxillofacial region markedly
expert and/or consensus opinion by experience researchers increases the potential for risks and complications in the
and clinicians. In addition, the manual Parameters of Care: pediatric population. Traumatic injuries involving the maxil-
Clinical Practice Guidelines for Oral and Maxillofacial Surgery,3 lofacial region can adversely affect growth, development, and
developed by the American Association of Oral and Maxil- function. Therefore, a thorough evaluation of the growing
lofacial Surgeons (AAOMS), was consulted. patient must be done before surgical interventions are per-
formed to minimize the risk of damage to the growing facial
General considerations complex.14
Surgery performed on pediatric patients involves special
considerations unique to this population. Several critical issues
deserve to be addressed.
ABBREVIATION
Preoperative considerations AAOMS: American Association of Oral and Maxillofacial Surgeons.
Informed consent AAPD: American Academy of Pediatric Dentistry. HPV: Human
Before any surgical procedure, informed consent must be papilloma virus. VKDB: Vitamin K deficiency bleeding.
obtained from the parent or legal guardian. For more infor-
mation, refer to AAPD's Informed Consent.4

Behavioral evaluation Ludwig’s angina.17,19 These conditions can be life threatening

Behavioral guidance of children in the operative and periopera- and may require immediate hospitalization with intravenous
tive periods presents a special challenge. Many children benefit antibiotics, incision and drainage, and referral/consultation
from modalities beyond local anesthesia and nitrous oxide/ with an oral and maxillofacial surgeon.17,19
oxygen inhalation to minimize their anxiety.4,14 Management
of children under sedation or general anesthesia requires Extraction of erupted teeth
extensive training and expertise.15,16 Special attention should be Maxillary and mandibular anterior teeth
given to the assessment of the social, emotional, and psycho- Most primary and permanent maxillary and mandibular central
logical status and cognitive level of the pediatric patient prior incisors, lateral incisors, and canines have conical single roots.
to surgery.14 Children have many unvoiced fears concerning In most cases, extraction of anterior teeth is accomplished
the surgical experience, and their psychological management with a rotational movement due to their single root
requires that the dentist be cognizant of their emotional anatomy.5 However, there have been reported cases of ac-
status. Answering questions concerning the surgery is impor- cessory roots observed in primary canines.21,22 Radiographic
tant and should be done in the presence of the parent. examination is helpful to identify differences in root anatomy
prior to extraction.21 Care should be taken to avoid placing
Peri- and post-operative considerations any force on adjacent teeth that could become luxated or
Metabolic management of children following surgery fre- dislodged easily due to their root anatomy.
quently is more complex than that of adults. Special consider-
ation should be given to caloric intake, fluid and electrolyte Maxillary and mandibular molars
management, and blood replacement. Comprehensive Primary molars have roots that are smaller in diameter and
management of the pediatric patient following extensive oral more divergent than permanent molars. Root fracture in
and maxillofacial surgery usually is best accomplished in a primary molars is not uncommon due to these characteristics
facility that has expertise and experience in the management as well as the potential weakening of the roots caused by the
of young patients (i.e., a children’s hospital).14 eruption of their permanent successors.5 Prior to extraction,
the relationship of the primary roots to the developing suc-
Recommendations cedaneous tooth should be assessed. To avoid inadvertent
Odontogenic infections extraction or dislocation of or trauma to the permanent
In children, odontogenic infections may involve more than successor, pressure should be avoided in the furcation area or
one tooth and usually are due to caries lesions, periodontal the tooth may need to be sectioned to protect the developing
problems, pathology (e.g., dens invaginatus), or a history of permanent tooth.
trauma. 17-18 Untreated odontogenic infections can lead to Molar extractions are accomplished by using slow conti-
pain, difficulty eating or drinking, abscess, cellulitis, septicemia, nuous palatal/lingual and buccal force allowing for the
airway compromise, and life-threatening infections.19 Facial expansion of the alveolar bone to accommodate the divergent
cellulitis results from unresolved abscess that has spread to roots and reduce the risk of root fracture.5 When extracting
cutaneous or subcutaneous soft tissue planes in the head and mandibular molars, care should be taken to support the
neck region.19 In these children, dehydration is a significant mandible to protect the temporomandibular joints from
consideration; prompt treatment of the source of infection is injury.5
imperative.
With infections of the upper portion of the face, patients Fractured primary tooth roots
usually complain of facial pain, fever, and malaise.20 Care must The presence of a root tip should not be regarded as a positive
be taken to rule out sinusitis or non-odontogenic infections, indication for its removal. The dilemma to consider when
as symptoms may mimic an odontogenic infection. Occasionally managing a retained primary tooth root is that removing the
in upper face infections, it may be difficult to find the true root tip may cause damage to the succedaneous tooth, while
cause.14 Infections of the lower face usually involve pain, swelling, leaving the root tip may increase the chance for postopera-
and trismus.3,17 They frequently are associated with teeth, skin, tive infection and delay eruption of the permanent successor.5
local lymph nodes, and salivary glands.17 Most odontogenic Radiographs can assist in the decision process. Expert opinion
infections occur in the upper face; however, infections in the suggests that if the fractured root tip can be removed easily,
mandibular region are more frequent in older children.20 it should be removed.5 If the root tip is very small, located
Most odontogenic infections can be managed with pulp deep in the socket, situated in close proximity to the permanent
therapy, extraction, or incision and drainage. 5 Infections of successor, or unable to be retrieved after several attempts, it is
odontogenic origin with systemic manifestations (e.g., elevated best left to be resorbed.5 The parent must be informed and a
temperature [102 to 104 degrees Fahrenheit], facial cellulitis, complete record of the discussion must be documented. The
difficulty in breathing or swallowing, fatigue, nausea) require patient should be monitored at appropriate intervals to eval-
antibiotic therapy.19 Severe but rare complications of odonto- uate for potential adverse effects.
genic infections include cavernous sinus thrombosis and

Management of unerupted and impacted teeth supports the removal of third molars when pathology (e.g.,
There is a wide clinical spectrum of disorders of eruption in cysts or tumors, caries, infection, pericoronitis, periodontal
both primary and permanent teeth in children. These may disease, detrimental changes of adjacent teeth or bone) is asso-
be syndromic or non-syndromic and include ankyloses,27-28 ciated and/or the tooth is malpositioned or nonfunctional
secondary retention,28 tooth impaction, or primary failure of (i.e., an unopposed tooth).37-39 There is no evidence to
eruption29. Clinically, it may be difficult to differentiate between support37-40 or refute3 the prophylactic removal of disease-free
the various disruptions; however, there have been many re- impacted third molars. Factors that increase the risk for
ports30,31 to assist the clinician in making a diagnosis. There is surgical complications (e.g., coexisting systemic conditions,
increasing evidence that there is a genetic etiology for some of location of peripheral nerves, history of temporomandibular
these eruption disruptions which may help in a definitive joint disease, presence of cysts or tumors)38,39 and position
diagnosis.29 Management of unerupted teeth will depend on and inclination of the molar in question41 should be assessed.
whether the tooth affected is likely to respond to orthodontic The age of the patient is only a secondary consideration.41
forces. If not, surgical extraction is the preferred treatment Referral to an oral and maxillofacial surgeon for consultation
option.29 and subsequent treatment may be indicated. When a decision
is made to retain impacted third molars, they should be
Impacted canines monitored for change in position and/or development of
Tooth impaction may occur due to a mechanical obstruction. pathology, which may necessitate later removal.
Permanent maxillary canines are second to third molars in
frequency of impaction.32 Early detection of an ectopically Supernumerary teeth
erupting canine through visual inspection, palpation, and Supernumerary teeth and hyperdontia are terms to describe
radiographic examination is important to maximize success of an excess in tooth number. Supernumerary teeth are thought
an intervention.33 Routine evaluation of patients in mid-mixed to be related to disturbances in the initiation and proliferation
dentition should involve identifying signs such as lack of ca- stages of dental development.21 Although some supernumerary
nine bulges and asymmetry in pattern of exfoliation. Abnormal teeth may be syndrome-associated (e.g., cleidocranial dysplasia)
angulation or ectopic eruption of developing permanent cus- or of familial inheritance pattern, most supernumerary teeth
pids can be assessed radiographically.33 When the cusp tip of occur as isolated events.21
the permanent canine is just mesial to or overlaying the distal Supernumerary teeth can occur in either the primary or
half of the long axis of the root of the permanent lateral incisor, permanent dentition.21,42,43 In 33 percent of the cases, a super-
canine palatal impaction usually occurs.32 Extraction of the numerary tooth in the primary dentition is followed by the
primary canines is the treatment of choice to correct palatally supernumerary tooth complement in the permanent denti-
displaced canines or to prevent resorption of adjacent teeth.32 tion.44 Reports in incidence of supernumerary teeth can be
One study showed that 78 percent of ectopically erupting as high as three percent, with the permanent dentition being
permanent canines normalized within 12 months after removal affected five times more frequently than the primary dentition
of the primary canines; 64 percent normalized when the and males being affected twice as frequently as females.21
starting canine position overlapped the lateral incisor by more Supernumerary teeth will occur 10 times more often in
than half of the root; and 91 percent normalized when the the maxillary arch versus the mandibular arch.21 Approxi-
starting canine position overlapped the lateral incisor by less mately 90 percent of all single tooth supernumerary teeth are
than half of the root.32 If no improvement in canine position found in the maxillary arch, with a strong predilection to the
occurs in a year, surgical and/or orthodontic treatment were anterior region.21,42 The maxillary anterior midline is the most
suggested.32,33 A Cochrane review34 and a systematic review35 common site, in which case the supernumerary tooth is known
reported no evidence to support extraction of primary canines as a mesiodens; the second most common site is the maxillary
to facilitate eruption of ectopic permanent maxillary canines. molar area, with the tooth known as a paramolar.21,42 A me-
A prospective randomized clinical trial demonstrated that siodens can be suspected if there is an asymmetric eruption
extraction of primary canines is an effective measure to correct pattern of the maxillary incisors, delayed eruption of the
palatally displaced maxillary canines and is more successful in maxillary incisors with or without any over-retained primary
children with an early diagnosis.36 Consultation between the incisors, or ectopic eruption of a maxillary incisor. 45 The
practitioner and an orthodontist may be useful in the final diagnosis of a mesiodens can be confirmed with radiographs,
treatment decision. including occlusal, periapical, or panoramic films,46 or com-
puted tomography.9,10 Three-dimensional information needed
Third molars to determine the location of the mesiodens or impacted tooth
Panoramic or periapical radiographic examination is indicated can be obtained by taking two periapical radiographs using
in late adolescence to assess the presence, position, and devel- either two projections taken at right angles to one another or
opment of third molars.7 The AAOMS recommends that a the tube shift technique (buccal object rule or Clark’s rule)47
decision to remove or retain third molars should be made or by cone beam computed tomography.10,12,13
before the middle of the third decade.3 Evidence-based research

Complications of supernumerary teeth can include delayed a soft diet, regular oral hygiene, and analgesics as needed.69 The
and/or lack of eruption of the permanent tooth, crowding, use of electrosurgery or laser technology for frenectomies has
resorption of adjacent teeth, dentigerous cyst formation, peri- demonstrated a shorter operative working time, a better ability
coronal space ossification, and crown resorption.42,48 Early to control bleeding, reduced intra- and post-operative pain and
diagnosis and appropriately timed treatment are important in discomfort, fewer post-operative complications (e.g., swelling,
the prevention and avoidance of these complications. Because infection), no need for suture removal, and increased patient
only 25 percent of all mesiodens erupt spontaneously, surgical acceptance.62,69,70 These procedures require extensive training as
management often is necessary.44,49 A mesiodens that is conical well as skillful technique and patient management.54,60,65,67,71-75
in shape and is not inverted has a better chance for eruption
than a mesiodens that is tubular in shape and is inverted.48 The Pediatric oral pathology
treatment objective for a non-erupting permanent mesiodens A wide spectrum of oral lesions occurs in children and ad-
is to minimize eruption problems for the permanent incisors.48 olescents, including soft and hard tissue lesions of the oral
Surgical management will vary depending on the size, shape, maxillofacial region. There is limited information on the
and number of supernumeraries and the patient’s dental prevalence of oral lesions in the pediatric population. The
development.48 The treatment objective for a non-erupting largest epidemiologic studies in the U.S. place the prevalence
primary mesiodens differs in that the removal of these teeth rate in children at four to 10 percent with the exclusion of
usually is not recommended, as the surgical intervention may infants.76,77 Although the vast majority of these lesions rep-
disrupt or damage the underlying developing permanent resent mucosal conditions, developmental anomalies, and
teeth.50 Erupted primary tooth mesiodens typically are left to reactive or inflammatory lesions, it is imperative to be vigilant
shed normally upon the eruption of the permanent dentition.50 for neoplastic diseases.
Extraction of an unerupted primary or permanent mesio- Regardless of the age of the child, it is important to estab-
dens is recommended during the mixed dentition to allow the lish a working diagnosis for every lesion. This is based on
normal eruptive force of the permanent incisor to bring itself obtaining a thorough history, assessing the risk factors and
into the oral cavity.43 Waiting until the adjacent incisors have documenting the clinical signs and symptoms of the lesion.
at least two-thirds root development will present less risk to Based on these facts, a list of lesions with similar characteris-
the developing teeth but still allow spontaneous eruption of tics is rank ordered from most likely to least likely diagnosis.
the incisors. 3 In 75 percent of the cases, extraction of the The entity that is judged to be the most likely disease becomes
mesiodens during the mixed dentition results in spontaneous the working diagnosis and determines the initial management
eruption and alignment of the adjacent teeth.50,51 If the adja- approach.
cent teeth do not erupt within six to 12 months, surgical For most oral lesions, a definitive diagnosis is best made by
exposure and orthodontic treatment may be necessary to aid performing a biopsy. By definition, a biopsy is the removal
their eruption.45,47 of a piece of tissue from a living body for diagnostic study
and is considered the gold standard of diagnostic tests.78 The
Frenulum attachments two most common biopsies are the incisional and excisional
Frenulum attachments and their role in oral function increas- types. Excisional biopsies usually are performed on small
ingly have become topics of interest among a variety of health lesions, less than one centimeter in size, for the total removal
care specialists. Ankyloglossia (tongue-tie) and hypertrophic/ of the affected tissue. An incisional biopsy is performed when
restrictive maxillary frenula have been implicated in difficulties a malignancy is suspected, the lesion is large in size or diffuse
breastfeeding53, incorrect speech articulation54,55, caries forma- in nature, or a multifocal distribution is present. Multiple
tion56,57, gingival recession58, and aberrant skeletal growth59. incisional biopsies may be indicated for diffuse lesions, in
Studies have shown differences in treatment recommendations order to obtain a representative tissue sample. Fine needle
among pediatricians, otolaryngologists, lactation consultants, aspiration, the cytobrush technique, and exfoliative cytology
speech pathologists, surgeons, and dental specialists.54,60-66 Clear may assist in making a diagnosis, but they are considered
indications and timing of surgical treatment remain controver- adjunctive tests because they do not establish a definitive
sial due to lack of consensus regarding accepted anatomical and diagnosis.79,80
diagnostic criteria for degree of restriction and relative impact It is considered the standard of care that any tissue
on growth, development, feeding, or oral motor function.54,60-66 removed from the oral and maxillofacial region be submitted
When indicated, frenuloplasty/frenotomy (various methods for histopathologic examination.81 Exceptions to this rule in-
to release the frenulum and correct the anatomic situation) or clude carious teeth that do not have soft tissue attached, extirpated
frenectomy (simple cutting of the frenulum) may be a successful pulpal tissue, and clinically normal tissue, such as tissue from
approach to alleviate the problem.54,60,65,67 Each of these proce- gingival recontouring.81 Gross description of all tissue that is
dures involves surgical incision, establishing hemostasis, and removed should be entered into the patient record. In general,
wound management.68 Dressing placement or the use of antibi- a soft tissue biopsy should be performed when a lesion persists
otics is not necessary.68 Recommendations include maintaining for greater than two weeks despite removal of the suspected

causative factor or empirical drug treatment. It is also imper- • lymphangioma;

ative to submit hard or soft tissue for evaluation to a pathologist • sialadentis;
if the differential diagnosis includes at least one significant • Burkitt’s lymphoma;
disease or neoplasm. Histopathologic examination not only • melanotic macule;
furnishes a definitive diagnosis, but it provides information • pleomorphic adenoma;
about the clinical behavior and prognosis and determines the • nevus; and
need for additional treatment or follow-up. Another valuable • neurofibroma.
outcome is that it allows the clinician to deliver evidence-based
medical/dental care, increasing the likelihood for a positive Lesions of the newborn
result.78 Furthermore, it presents important documentation Palatal cysts of the newborn include Epstein pearls and Bohn
about the lesion for the patient record, including the pro- nodules. These cysts are found in up to 85 percent of new-
cedures taken for establishing a diagnosis.78 borns.53,83-90 Epstein pearls occur in the median palatal raphe
Many oral biopsies are within the scope of practice for a area53,83-85 as a result of trapped epithelial remnants along the
pediatric dentist to perform. However, if the tissue is excised, line of fusion of the palatal halves. 49,51 Bohn nodules are
the following steps should be taken for optimum results:78-81 remnants of salivary gland epithelium and usually are found
1. select the most representative lesion site and not the area on the buccal and lingual aspects of the ridge, away from the
that is the most accessible. midline.83,85 Gingival cysts of the newborn, or dental lamina
2. remove an adequate amount of tissue. If the biopsy is too cysts, are found on the crests of the dental ridges, and are most
small or too superficial, a diagnosis may be compromised. commonly are seen bilaterally in the region of the first pri-
3. avoid crushing or distorting the tissue. Damage is most mary molars.84 They result from remnants of the dental lamina.
often observed from the forces of the tissue forceps, Palatal and gingival cysts of the newborn typically present as
tearing the tissues or overheating the tissue from the use asymptomatic one to three millimeter nodules or papules.
of electrosurgery or laser removal. They are smooth, whitish in appearance, and filled with
4. immediately place the tissue in a fixative, which for most keratin.83,84 No treatment is required, as these cysts usually
samples is 10 percent formalin. It is critical not to dilute disappear during the first three months of life.53,83
the fixative with water or other liquids because tissue
autolysis will render the sample nondiagnositic. Congenital epulis of the newborn
5. proper identification of the specimen is essential. The Congenital epulis of the newborn, also known as granular
formalin container should be labelled with the name cell tumor or Neumann’s tumor, is a rare benign tumor seen
of the patient and the location. Multiple tissue samples only in newborns. 91 This lesion is typically a protuberant
from different locations should not be placed in the mass arising from the gingival mucosa. It is most often
same container, unless they are uniquely identified, such found on the anterior maxillary ridge.86,87 Patients typically
as tagged with a suture. present with feeding and/or respiratory problems.87 Congenital
6. complete the surgical pathology form including patient epulis has a marked predilection for females at 8:1 to 10:1.86-88
demographics, the submitting dentist’s name and address, Treatment normally consists of surgical excision. 86-88 The
and a brief but accurate history. It is important to have newborn usually heals well, and no future complications or
legible records so that the diagnosis is not delayed. treatment should be expected. Congenital epulis never recurs
Clinical photographs and radiographs often are very after excision. 88 There have been reports of spontaneous
useful for correlating the microscopic findings. regression of untreated congenital epulis.88,91
Worldwide, the most frequently oral biopsied lesions in Melanotic neuroectodermal tumor of infancy
children include82: Melanotic neuroectodermal tumor of infancy is a rare occur-
• mucocele; rence that develops during the first year of life.88 This lesion
• fibrous lesions; may be present at birth. It occurs in the anterior maxilla 70
• pyogenic granuloma; percent of the time.83 Less frequently, melanotic neuroecto-
• dental follicle; dermal tumor of infancy occurs in the skull, mandible,
• human papillomavirus (HPV) lesion; epididymis and testis, and brain.83,88 The classic presentation
• chronic inflammation; is a bluish or black rapidly expanding mass of the anterior
• giant cell lesions (soft tissue); maxilla. Radiographic findings include an ill-defined
• hyperkeratosis; unilocular radiolucency with the displacement of tooth buds.88
• peripheral ossifying fibroma; There can be a floating tooth appearance.83 Surgical excision is
• gingivitis; required, and there is a 20 percent recurrence rate. Although
• gingival hyperplasia; this is a benign lesion, seven percent of reported cases have
• hemangioma; behaved malignantly resulting in metastasis and death.88
• ulcer;

Natal and neonatal teeth Mucocele

Natal and neonatal teeth can present a challenge when deciding The mucocele is a common lesion in children and adolescents
on appropriate treatment. Natal teeth have been defined as resulting from the rupture of a minor salivary gland excretory
those teeth present at birth, and neonatal teeth are those that duct, with subsequent leakage of mucin into the adjacent
erupt during the first 30 days of life.92,93 The occurrence of connective tissues that later may be surrounded in a fibrous
natal and neonatal teeth is rare; the incidence varies from capsule.83,85,99-101 Most mucoceles are well-circumscribed bluish
1:1,000 to 1:30,000.92,93 The teeth most often affected are the translucent fluctuant swellings that are firm to palpation,
mandibular primary incisors.94 In most cases, anterior natal although deeper and long-standing lesions may range from
and neonatal teeth are part of the normal complement of the normal in color to having a whitish keratinized surface.85,99,100
dentition.92,93 Natal or neonatal molars have been identified in Mucoceles most frequently are observed on the lower lip, usually
the posterior region and may be associated with systemic condi- lateral to the midline.88 Mucoceles also can be found on the
tions or syndromes (e.g., Pfieffer syndrome, histiocytosis X).94-96 buccal mucosa, ventral surface of the tongue, retromolar region,
Although many theories exist as to why the teeth erupt prema- and floor of the mouth (ranula).99-101 Superficial mucoceles and
turely, currently no studies confirm a causal relationship with some other mucoceles are short-lived lesions that burst spon-
any of the proposed theories. The superficial position of the taneously, leaving shallow ulcers that heal within a few
tooth germ associated with a hereditary factor seems to be the days.85,100 Local mechanical trauma to the minor salivary gland
most accepted possibility.93 is often the cause of rupture.50,53,86,87 Many lesions, however,
If the tooth is not excessively mobile or causing feeding require treatment to minimize the risk of recurrence.85,100
problems, it should be preserved and maintained in a healthy
condition if possible.93,95,96 Close monitoring is indicated to Squamous papilloma
ensure that the tooth remains stable and is not an aspiration Squamous papilloma is a benign human papillomavirus-
risk to the infant. induced lesion caused by HPV types 1 and 6. 83 Squamous
Riga-Fede disease is a condition caused by the natal or papilloma presents as soft painless, pink to white, pedunculated
neonatal tooth rubbing the ventral surface of the tongue (stalked) lesions. The surface may display multiple fingerlike
during feeding, leading to ulceration.75,92 Failure to diagnose projections and may have a cauliflower like appearance.83,102,103
and properly treat this lesion can result in dehydration and These lesions can occur anywhere in the oral cavity, but the
inadequate nutritional intake for the infant. 96 Treatment tongue, lips and soft palate are the most common sites. 103
should be conservative and focus on creating round, smooth Squamous papilloma generally occurs in adulthood, but 20
incisal edges.93-96 If conservative treatment does not correct the percent have been noted prior to age 20.91 Although they are
condition, extraction is the treatment of choice.93-96 viral in origin, the infectivity is low.83,102 Squamous papilloma
An important consideration when deciding to extract a natal do not have malignant potential.103 Excision is the treatment
or neonatal tooth is the potential for hemorrhage. Extraction of choice, and recurrence is uncommon.83,103
is contraindicated in newborns due to risk of hemorrhage.97
Unless the child is at least 10 days old, consultation with the Verruca vulgaris
pediatrician regarding adequate hemostasis may be indicated Verruca vulgaris, or the common wart, is an HPV type 2
prior to extraction of the tooth. In particular, infants may be induced lesion that is generally found on the skin of the
at risk for vitamin K deficiency bleeding (VKDB) if they did hand.102 Finger or thumb sucking can cause autoinoculation
not receive a dose of vitamin K shortly after birth (within 6 resulting in the development of intraoral lesions. 102 Verruca
hours of birth).98 Infants can be at risk for VKDB until the vulgaris is similar in appearance to the squamous papilloma.
age of 6 months if they do not receive a vitamin K injection.98 This lesion can be sessile (broad based) or pedunculated and
can display a rough bumpy surface.103 Verruca vulgaris can be
Lesions occurring in children and adolescents found on the lips, tip of tongue, and labial mucosa.83 There is
Eruption cyst (eruption hematoma) no risk of malignant transformation.83 Excision of the entire
The eruption cyst is a soft tissue cyst that results from a lesion is recommended and recurrence is uncommon.103
separation of the dental follicle from the crown of an erupting
tooth.83,99 Fluid accumulation occurs within this created fol- Irritation fibroma
licular space.85,89,100 Eruption cysts most commonly are found in The irritation fibroma is a reactive lesion occurring as a re-
the mandibular molar region.89 Color of these lesions can range sponse to chronic trauma of the mucosa. The irritation fibroma
from normal to blue-black or brown, depending on the amount presents as a firm nontender pink nodule and is composed of
of blood in the cystic fluid.85,89,100 The blood is secondary to fibrous connective tissue.103 The lesion does not exceed two
trauma. If trauma is intense, these blood-filled lesions some- millimeters in diameter.104 The irritation fibroma can be found
times are referred to as eruption hematomas.85,89,100 Because the on buccal and labial mucosa, the tongue, and attached gingiva.
tooth erupts through the lesion, no treatment is necessary.85,89,100 Excisional biopsy is recommended. These can reoccur if the
If the cyst does not rupture spontaneously or the lesion becomes source of the irritation is not removed.103,104
infected, the roof of the cyst may be opened surgically.85,89

Recurrent aphthous stomatitis attached gingiva (75 percent) but can be found on tongue,
Recurrent aphthous stomatitis is one of the most common oral lower lip, or buccal mucosa.108 Treatment is complete ex-
lesions, occurring in 20-30 percent of children.83 Recurrent cision with the removal of the source of irritant. 83,108 This
aphthous stomatitis is caused by a T-cell mediated immu- lesion can recur in 3-15 percent of cases.83
nologic reaction to a triggering agent. 105 Three variants of
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neck. In: Oral Pathology: Clinical-Pathologic Correlations. disease. In: Oral and Maxillofacial Pathology. 4th ed. St.
7th ed. St. Louis, Mo.: Elsevier; 2017:245-68. Louis, Mo.: Elsevier; 2016:140-63.
91. McDonald JS. Tumors of the oral soft tissues and cysts 108. Regezi J, Sciubba J, Jordan R. Red-blue lesions. In: Oral
and tumors of bone. In: Dean JA ed. McDonald and Pathology: Clinical-Pathologic Correlations. 7th ed. St.
Avery’s Dentistry for the Child and Adolescent. 10th ed. Louis, Mo.: Elsevier; 2017:114-33.
St. Louis, Mo.: Elsivier; 2016:603-26.

BEST PRACTICES: USE OF ANTIBIOTIC THERAPY
Use of Antibiotic Therapy for Pediatric Dental

Patients
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Use of anti-
2019 biotic therapy for pediatric dental patients. The Reference Manual of
Purpose such as allergic reactions, development of C. difficile, or drug

The American Academy of Pediatric Dentistry (AAPD) interactions and side effects can occur.6,9 The Centers for
recognizes the increasing prevalence of antibiotic-resistant Disease Control and Prevention reports that every year there
microorganisms and potential for adverse drug reactions and are 140,000 emergency department visits for reactions to anti-
interactions. These recommendations are intended to provide biotics, and that antibiotics are the most common cause of
guidance in the proper and judicious use of antibiotic therapy emergency department visits for adverse drug events in
in the treatment of oral conditions. The use of antibiotic children under the age of 18 years.6
prophylaxis for dental patients at risk for infection is ad-
dressed in a separate best practices document.1 Information Recommendations
regarding commonly prescribed antibiotics can be found in Practitioners should adhere to the following general principles
the AAPD’s Useful Medications for Oral Conditions.2 when prescribing antibiotics for the pediatric population.
Methods Oral wounds

Recommendations on the use of antibiotic therapy were Factors related to host risk (e.g., age, systemic illness, co-
developed by the Council on Clinical Affairs and adopted in morbidities, malnutrition) and type of wound (e.g., laceration,
2001.3 This document is a revision of the previous version, last puncture) must be evaluated when determining the risk for
revised in 2014.4 The revision was based upon a new literature infection and subsequent need for antibiotics. Wounds can be
®
antibiotic therapy, antibacterial agents, antimicrobial agents,
classified as clean, potentially contaminated, or contaminated/
dirty. Facial lacerations and puncture wounds may require
dental trauma, oral wound management, orofacial infections, topical antibiotic agents.10 Intraoral puncture wounds and
periodontal disease, viral disease, and oral contraception; fields: lacerations that appear to have been contaminated by extrinsic
all; limits: within the last 10 years, humans, English, clinical bacteria, debris (e.g., dirt, soil, gravel), foreign body, open
trials, birth through age 18. Three hundred forty-three articles fractures, and joint injury have an increased risk of infection
matched these criteria. Papers for review were chosen from and should be managed by systemic antibiotics.10 Tetanus
this search and from hand searching. When data did not immunization status should be determined. If it is decided
appear sufficient or were inconclusive, recommendations were that antibiotics would be beneficial to the healing process, the
based upon expert and/or consensus opinion by experienced timing of the administration of antibiotics is critical to sup-
researchers and clinicians. plement the natural host resistance in bacterial killing. The
drug should be administered as soon as possible for the best
Background result. The most effective route of drug administration (intra-
Antibiotics are beneficial to patient care when prescribed and venous vs. intramuscular vs. oral) must be considered. The
administered correctly for bacterial infections. However, the clinical effectiveness of the drug must be monitored. The
widespread use of antibiotics has permitted common bacteria minimal duration of drug therapy should be five days beyond
to develop resistance to drugs that once controlled them.6-7 the point of substantial improvement or resolution of signs
Drug resistance is prevalent throughout the world.6,7 In the and symptoms; this is usually a five- to seven-day course of
United States, at least two million people are infected by treatment dependent upon the specific drug selected.11,12 In
antibiotic-resistant bacteria per year.6 Some microorganisms light of the growing problem of drug resistance, the clinician
may develop resistance to a single anti-microbial agent, while
others develop multidrug-resistant strains.7 To diminish the
rate at which resistance is increasing, health care providers ABBREVIATIONS
must be prudent in the use of antibiotics.6,8 Conservative use AAPD: American Academy Pediatric Dentistry. JRP: Juvenile
of antibiotics is indicated to minimize the risk of developing recurrent parotitis.
resistance to current antibiotic regimens.6,7 Adverse events

should consider altering or discontinuing antibiotics follow- Penicillin V or amoxicillin can be given as an alternative in
ing determination of either ineffectiveness or cure prior to patients under 12 years of age.18,19 The use of topical antibiotics
completion of a full course of therapy.13 If the infection is not (minocycline or doxycycline) to enhance pulpal revascular-
responsive to the initial drug selection, a culture and sensitiv- ization and periodontal healing in immature non-vital
ity testing of a swab from the infective site or, in some cases, traumatized teeth has shown some potential.18,19,20 However,
a blood microbiology and culture and sensitivity may be further randomized clinical trials are needed.21,22 For luxation
indicated. injuries in the primary dentition, antibiotics are not indicated.18
Antibiotics can be warranted in cases of concomitant soft
Pulpitis/apical periodontitis/draining sinus tract/localized tissue injuries (see Oral wounds) and when dictated by the
intra-oral swelling patient’s medical status.
Bacteria can gain access to the pulpal tissue through caries,
exposed pulp or dentinal tubules, cracks into the dentin, and Pediatric periodontal diseases
defective restorations. If a child presents with acute symp- Gingival inflammation due to the presence of bacterial plaque
toms of pulpitis, treatment (i.e., pulpotomy, pulpectomy, or accumulation is a key factor in the development of periodontal
extraction) should be rendered. Antibiotic therapy usually disease and must be controlled.23 However, a distinction must
is not indicated nor effective if the dental infection is con- be made between a site of gingival inflammation versus a
tained within the pulpal tissue or the immediate surrounding gingival case, diagnosed at the patient level, using specific cri-
tissue. In this case, the child will have no systemic signs of an teria, including bleeding on probing.24 Periodontal diseases
infection (i.e., no fever and no facial swelling).5 recently have been classified into three groups: 1) periodontal
Consideration for use of antibiotics should be given in health, gingival diseases, and conditions; 2) periodontitis and;
cases of advanced non-odontogenic bacterial infections such as 3) other conditions affecting the periodontium;25 periodontitis
staphylococcal mucositis, tuberculosis, gonococcal stomatitis, is further classified as necrotizing periodontal disease, periodon-
and oral syphilis. If suspected, it is best to refer patients for titis as manifestation of systemic diseases, and periodontitis. 25
microbiology, culture and sensitivity, biopsy, or other laboratory Prior terms of chronic or aggressive periodontitis are now
tests for documentation and definitive treatment. included in the single category of periodontitis. 26 Dental
plaque-induced gingivitis is managed by appropriate local
Acute facial swelling of dental origin therapeutic interventions22 including professional oral hygiene
A child presenting with a facial swelling or facial cellulitis and re-enforcement of brushing twice daily for at least two
secondary to an odontogenic infection should receive prompt minutes.27 Patients diagnosed with what formerly was known
dental attention. In most situations, immediate surgical inter- as aggressive periodontal disease may require adjunctive anti-
vention is appropriate and contributes to a more rapid cure.14 microbial therapy in conjunction with localized treatment.28-31
The clinician should consider age, cooperation, the ability to In pediatric periodontal diseases associated with systemic
obtain adequate anesthesia (local vs. general), the severity of disease (e.g., severe congenital neutropenia, Papillon-Lefèvre
the infection, the medical status, and any social issues of the syndrome, leukocyte adhesion deficiency), the immune sys-
child.14,15 Signs of systemic involvement and septicemia (e.g., tem is unable to control the growth of periodontal pathogens
fever, malaise, asymmetry, facial swelling, lymphadenopathy, and, in some cases, treatment may involve antibiotic therapy.28,32
trismus, tachycardia, dysphagia, respiratory distress) warrant In severe and refractory cases, extraction is indicated. 28,32
emergency treatment. Additional testing such as a complete Culture and susceptibility testing of isolates from the involved
blood examination, c-reactive protein, blood cultures, and sites are helpful in guiding the drug selection.28,32
bacterial culture and sensitivity can aid in assessment and
diagnosis. Intravenous antibiotic therapy medical management Viral diseases
is indicated.14,15 Penicillin derivatives remain the empirical Conditions of viral origin such as acute primary herpetic
choice for odontogenic infections; however, consideration of gingivostomatitis should not be treated with antibiotic therapy.9
additional adjunctive antimicrobial therapy (i.e., metronidazole)
can be given where there is anaerobic bacterial involvement.13,16 Salivary gland infections
Cephalosporins could be considered as an alternative choice For acute salivary gland swellings of bacterial nature, antibiotic
for odontogenic infections.16 therapy is indicated.33 If the patient does not improve in 24-48
hours on antibiotics alone, incision and drainage may be war-
Dental trauma ranted.6 Amoxicillin/clavulanate is used as empirical therapy
Systemic antibiotics have been recommended as adjunctive to cover both staphylococcal and streptococcal species as most
therapy for avulsed permanent incisors with an open or closed bacterial infections of the salivary glands originate from oral
apex.17,18 Tetracycline (doxycycline twice daily for seven days) flora.33 Clindamycin is appropriate for penicillin allergic pa-
is the drug of choice, but consideration of the child’s age tients. 30 The most common inflammatory salivary gland
must be exercised in the systemic use of tetracycline due to the disorder in the U.S. is juvenile recurrent parotitis (JRP), with
risk of discoloration in the developing permanent dentition.18 first onset of symptoms between ages 3-6 years old, continuing

to puberty.33 Although JRP is self-limiting, administration of resistance in individual patients: Systematic review and
`-lacatam antibiotics can shorten symptom duration.33 For meta-analysis. BMJ 2010;340:c2096.
both acute bacterial submandibular sialadenitis and chronic 8. Aidasani B, Solankis M, Khetarpal S, Ravi Pratap S.
recurrent submandibular sialadenitis, antibiotic therapy is Antibiotics: Their use and misuse in paediatric dentistry.
included as part of the treatment.34 A systematic review. Eur J Paediatr Dent 2019;20(2):
133-8.
Oral contraceptive use 9. Centers for Disease Control and Prevention. Antibiotic
Although caution is advised with the concomitant use of anti- Prescribing and Use. Antibiotic Use in Outpatient Settings,
biotics and oral contraceptives,35,36 a 2018 systematic review 2017. Available at: “https://www.cdc.gov/antibiotic-use/
of drug interactions between non-rifamycin antibiotics and stewardship-report/outpatient.html”. Accessed October
hormonal contraception found that most women can expect 9, 2019.
no reduction in hormonal contraceptive effect with the con- 10. Nakamura Y, Daya M. Use of appropriate antimicrobials
current use of non-rifamycin antibiotics.37 The World Health in wound management. Emerg Med Clin North Am
Organization also reported in 2015 that most broad-spectrum 2007;25(1):159-76.
antibiotics do not affect the contraceptive effectiveness of 11. Kuriyama T, Karasawa T, Nakagawa K, Saiki Y, Yamamoto
combined oral contraceptives, combined contraceptive patch, E, Nakamura S. Bacteriological features and antimicro-
or the combined contraceptive vaginal ring.38 In addition, no bial susceptibility in isolates from orofacial odontogenic
differences in ovulation were found when oral contraceptives infections. Oral Surg Oral Med Oral Pathol Oral Radiol
were combined with ampicillin, doxycycline, temafloxacin, Endod 2000;90(5):600-8.
ofloxacin, ciprofloxacin, clarithromycin, roxithromycin, dirithro- 12. Prieto-Prieto J, Calvo A. Microbiological basis of oral
mycin, or metronidazole.37 Women should be encouraged to infections and sensitivity to antibiotics. Med Oral Patol
take oral contraceptives correctly and consistently at all times, Oral Cir Bucal 2004;9(suppl S):11-8.
including during periods of illness. 37 Rifamcyin antibiotics, 13. Flynn T. What are the antibiotics of choice for odonto-
such as rifampin or rifabutin, induce hepatic enzymes that are genic infections, and how long should the treatment
required for hormonal contraceptive metabolism, which could course last? Oral Maxillofac Surg Clin North Am 2011;
compromise the contraceptive or antibiotic effect.37,38 Use of 23(4):519-36.
other contraceptives should be advised with long-term use 14. Johri A, Piecuch JF. Should teeth be extracted immediately
of these medications.38 in the presence of acute infection? Oral Maxillofac Surg
Clin North Am 2011;23(4):507-11.
References 15. Thikkurissy S, Rawlins JT, Kumar A, Evans E, Casamassimo
1. American Academy of Pediatric Dentistry. Antibiotic PS. Rapid treatment reduces hospitalization for pediatric
prophylaxis for dental patients at risk for infection. patients with odontogenic-based cellulitis. Am J Emerg
The Reference Manual of Pediatric Dentistry. Chicago, Med 2010;28(6):668-72.
Ill.: American Academy of Pediatric Dentistry; 2019: 16. Zirk M, Buller J, Goeddertz P, et al. Empiric systemic
416-21. antibiotics for hospitalized patients with severe odonto-
2. American Academy of Pediatric Dentistry. Useful med- genic infections. J Craniomaxillofac Surg 2016;44(8):
ications for oral conditions. The Reference Manual of 1081-8.
Pediatric Dentistry. Chicago, Ill.: American Academy of 17. DiAngelis AJ, Andreasen JO, Ebelseder KA, et al. Interna-
Pediatric Dentistry; 2019:544-50. tional Association of Dental Traumatology Guidelines for
3. American Academy of Pediatric Dentistry. Appropriate the management of traumatic dental injuries: 1 – Fractures
use of antibiotic therapy. Pediatr Dent 2001;23(special and luxations of permanent teeth. Dent Traumatol 2012;
issue):71-3. 28(2):2-12.
4. American Academy of Pediatric Dentistry. Use of anti- 18. Andersson L, Andreasen JO, Day P, et al. International
biotic therapy for pediatric dental patients. Pediatr Dent Association of Dental Traumatology Guidelines for the
2014;36(special issue):284-6. management of traumatic dental injuries: 2 – Avulsion of
5. Fluent MT, Jacobsen PL, Hicks LA. Considerations for permanent teeth. Dent Traumatol 2012;28(2):88-96.
responsible antibiotic use in dentistry. J Am Dent Assoc 19. Malmgren B, Andreasen JO, Flores MT, et al. International
2016;147(8):683-6. Association of Dental Traumatology Guidelines for the
6. Centers for Disease Control and Prevention. Antibiotic/ management of traumatic dental injuries: 3. Injuries in the
Antimicrobial Resistance Threats in the United States, primary dentition. Dent Traumatol 2012;28(3):174-82.
2013. Available at: “https://www.cdc.gov/drugresistance/ 20. McIntyre JD, Lee JY, Trope M, Vann WF Jr. Management
threat-report-2013/pdf/ar-threats-2013-508.pdf ”. Accessed of avulsed permanent incisors: A comprehensive update.
October 9, 2019. Pediatr Dent 2007;29(1):56-63.
7. Costelloe C, Metcalfe C, Lovering A, et al. Effect of
antibiotic prescribing in primary care on antimicrobial References continued on the next page.

21. Hargreaves KM, Diogenes A, Teixeira FB. Treatment 30. Rabelo CC, Feres M, Gocalves C, et al. Systematic anti-
options: Biological basis of regenerative endodontic biotics in the treatment of aggressive periodontitis. A
procedures. Pediatr Dent 2013;35(2):129-40. systematic review and a Bayesian Network meta-analysis.
22. Shabahang S. Treatment options: Apexogenesis and J Clin Periodontol 2015;42(7):647-57.
apexification. Pediatr Dent 2013;35(2):125-8. 31. Merchant H. Vovk A, Kalash D, et al. Localized aggressive
23. Murakami S, Mealey B, Mariotti A, Chapple I. Dental periodontitis treatment response in primary and perma-
plaque induced gingival conditions. J Periodontol 2018; nent dentitions. J Periodontol 2014;85(12):1722-9.
89(Suppl 1):S17-S27. 32. Schmidt JC, Wlater C, Rischewski JR, Weiger R. Treat-
24. Trombelli L, Farina R, Silva C, Tatakis D. Plaque induced ment of periodontitis as a manifestation of neutropenia
gingivitis: Case definition and diagnostic considerations. with or without systemic antibiotics: A systematic review.
J Periodontol 2018;89(Suppl 1):S46-S73. Pediatr Dent 2013;35(2):E54-E63.
25. Caton JC, Armitage G, Berglundh T, et al. A new 33. Patel A, Karlis V. Diagnosis and management of pediatric
classification scheme for periodontal and peri-implant salivary gland infections. Oral Maxillofacial Surg Clin
diseases and conditions: Introduction and key changes North Am 2009;21:345-52.
from the 1999 classification. J Periodontol 2018;89(Suppl 34. Carlson ER. Diagnosis and management of salivary gland
1):S1-S8. infections. Oral Maxillofac Surg Clin North Am 2009;
26. Papapanou PN, Sanz M, Buduneli N, et al. Periodontitis: 21(3):293-312.
Consensus report of Workgroup 2 of the 2017 World 35. DeRossi SS, Hersh EV. Antibiotics and oral contraceptives.
Workshop on the Classification of Periodontal and Peri- Pediatr Clin North Am 2002;46(4):653-64.
Implant Diseases and Conditions. J Periodontol 2018;89 36. Becker DE. Adverse drug interactions. Anesth Prog 2011;
(Suppl 1):S173-S182. Available at: “https://doi.org/10. 58(1):31-41.
1002/JPER.17-0721”. Accessed August 10, 2019. 37. Simmons K, Haddad L, Nanda K, Curtis, K. Drug inter-
27. Chapple IL, Van der Weijden F, Doerfer C, et al. Primary actions between non-rifamycin antibiotics and hormonal
prevention of periodontitis: Managing gingivitis. J Clin contraception: A systematic review. Am J Obstet Gynecol
Periodontol 2015;42(Suppl 16):S71-S76. 2018;218(1):88-97.
28. American Academy of Periodontology Research, Science 38. World Health Organization. Medical Eligibility Criteria
and Therapy Committee. Periodontal diseases of children for Contraceptive Use. 5th ed. Geneva, Switzerland:
and adolescents. J Periodontol 2003;74:1696-704. World Health Organization; 2015. Available at: “https://
29. Keestra JAJ, Grosjean I, Coucke W, Quirynen M, Teughels www.who.int/reproductivehealth/publications/family
W. Non-surgical periodontal therapy with systemic anti- _planning/MEC-5/en/”. Accessed July 11, 2019.
biotics in patients with untreated aggressive periodontitis:
A systematic review and meta-analysis. J Periodont Res
2015;50(6):689-706.

BEST PRACTICES: ANTIBIOTIC PROPHYLAXIS
Antibiotic Prophylaxis for Dental Patients at Risk

for Infection
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Antibiotic pro-
2019 phylaxis for dental patients at risk for infection. The Reference Manual
Dentistry; 2020:447-52.
Purpose Antibiotic usage may result in the development of resistant

The American Academy of Pediatric Dentistry (AAPD) recog- organisms. 3,6,7,9-11 Utilization of antibiotic prophylaxis for
nizes that numerous medical conditions predispose patients patients at risk does not provide absolute prevention of
to bacteremia-induced infections. Because it is not possible to infection. Post-procedural symptoms of acute infection (e.g.,
predict when a susceptible patient will develop an infection, fever, malaise, weakness, lethargy) may indicate antibiotic
prophylactic antibiotics are recommended when these patients failure and need for further medical evaluation.
undergo procedures that are at risk for producing bacteremia. The decision to use antibiotic prophylaxis should be made
These recommendations are intended to help practitioners on an individual basis. Some medical conditions that may
make decisions regarding antibiotic prophylaxis for dental predispose patients to post-procedural infections are discussed
patients at risk. below. This is not intended to be an exhaustive list; rather,
the categorization should help practitioners identify children
Methods who may be at increased risk. If a patient reports a syndrome
Recommendations on antibiotic prophylaxis for dental or medical condition with which the practitioner is not
patients at risk for infection were developed by the Clinical familiar, it is appropriate to contact the child’s physician to
Affairs Committee and adopted in 1990.1 This document by determine susceptibility to bacteremia-induced infections.
the Council of Clinical Affairs is a revision of the previous To date, the evidence base supporting the efficacy and use
version, last revised in 20142, and based on a review of current of antibiotic prophylaxis is limited, especially in the pediatric
dental and medical literature pertaining to post-procedural population. Many of the indications are based on consen-
bacteremia-induced infections. This revision included database sus.4,12-14 The conservative use of antibiotics is indicated to
searches using key terms: infective endocarditis (IE), bac- minimize the risk of developing resistance to current antibiotic
teremia, antibiotic prophylaxis, and dental infection. Articles regimens. 3,9,15,16 Given the increasing number of organisms
were evaluated by title and/or abstract and relevance to that have developed resistance to current antibiotic regimens,
dental care for children, adolescents, and those with special as well as the potential for an adverse anaphylactic reaction
health care needs. Thirty-five citations were chosen from this to the drug administered, it is best to be judicious in the use
method and from references within selected articles. When of antibiotics for the prevention of IE3 or other distant-site
data did not appear sufficient or were inconclusive, recom- infections.9,11,17
mendations were based upon expert and/or consensus opinion
by experienced researchers and clinicians. In addition, Recommendations
Prevention of infective endocarditis: Guidelines from the American Antibiotic prophylaxis is recommended with certain dental
Heart Association,3 Infective Endocarditis in Childhood: 2015 procedures,3,4,6,8,18 but this should be directed against the most
Update: A Scientific Statement From the American Heart Associ- likely infecting organism. When procedures involve infected
ation,4 and the American Dental Association (ADA) report tissues or are performed on a patient with a compromised
The Use of Prophylactic Antibiotics Prior to Dental Procedures host response, additional doses or a prescribed pre- and post-
in Patients with Prosthetic Joints 5 were reviewed. operative regimen of antibiotics may be necessary. Emphasis
should be placed on the prevention of disease, establishment of
Background good oral health care habits, and routine oral health assessments
Bacteremia (bacteria in the bloodstream) is anticipated follow-
ing invasive dental procedures and can lead to complications
in an immunodeficient patient. 6,7 High risk cardiac disease, ABBREVIATIONS
immunosuppression, and immunodeficiencies may compromise AAPD: American Academy of Pediatric Dentistry. ADA: American
Dental Association. AHA: American Heart Association. CIED: Cardio-
one’s ability to fight simple infection. The rationale for anti-
vascular implantable electronic device. GI: Gastrointestinal. GU:
biotic prophylaxis is to reduce or eliminate transient bacteremia Genitourinary. IE: Infective endocarditis.
caused by invasive dental procedures.8

through a dental home. This may prevent the frequent need be on maintaining good oral hygiene, routine dental examina-
for the use of antibiotic therapy and, thus, decrease the risks tions, infection control to reduce bacteremia, and discouraging
of resistance and adverse events relation to use of antibiotics.8,19,20 tattooing or piercing rather than relying on antibiotic pro-
phylaxis for patients at risk. 13,14,18-20.23 These patients and
Patients with cardiac conditions their parents need to be educated and motivated to maintain
Infective endocarditis is an example of an uncommon but personal oral hygiene through daily plaque removal, including
life-threatening complication resulting from bacteremia. The flossing.3 There is a shift in the emphasis on improved access
incidence of pediatric admissions due to infective endocarditis to dental care and oral health in patients with underlying
was between 0.05 and 0.12 cases per 1000 admissions in a cardiac conditions at high risk for IE and less focus on a dental
multicenter study of U.S. children’s hospitals from 2003- procedure and antibiotic coverage.4 Professional prevention
2010.4 Only a limited number of bacterial species have been strategies should be based upon the individual’s assessed risk
implicated in resultant postoperative infections; Viridans group for caries and periodontal disease.
streptococci, Staphylococcus aureus and Enterococcus species are In addition to those diagnoses listed in the AHA guidelines,
the main microorganisms implicated in IE.3,4 Enterococcal and patients with a reported history of injection drug use may be
other organisms such as Haemophilus species, Aggregatibacter considered at risk for developing IE in the absence of cardiac
species, Cardiobacterium hominis, Eikenella corrodens, and anomalies.22 Patients also should be discouraged from tattooing
Kingella species are less common. 4 Routine daily activities and piercing.13,14,24 Consultation with the patient’s physician
such as toothbrushing, flossing, and chewing contribute more may be necessary to determine susceptibility to bacteremia-
to the incidence of bacteremia when compared to dental pro- induced infections.
cedures.4 Thus, focus has shifted from antibiotic prophylaxis Antibiotics are recommended for all dental procedures that
to an emphasis on oral hygiene and the prevention of oral involve manipulation of gingival tissue or the periapical region
diseases.4,8,13,14,18,20 of teeth or perforation of the oral mucosa for cardiac patients
In 2007, the American Heart Association (AHA) revised its with the highest risk3 (see Tables 1 and 2). Specific antibiotic
guidelines for the prevention of IE and reducing the risk for regimens can be found in Table 3. Practitioners and patients/
producing resistant strains of bacteria.3 The significant reasons parents can review the entire AHA guidelines in the AHA
for the revision include3: Circulation archives3 (available at “http://circ.ahajournals.org/
• “IE is much more likely to result from frequent exposure cgi/content/full/116/15/1736”) for additional background
to random bacteremias associated with daily activities information as well as discussion of special circumstances
than from bacteremia caused by a dental, [gastrointes- (e.g., patients already receiving antibiotic therapy, patients on
tinal] GI tract, or [genitourinary] GU tract procedure.”3 anti-coagulant therapy).
Daily activities would include toothbrushing, floss-
ing, chewing, using toothpicks, using water irrigation Patients with compromised immunity
devices, and other activities. Non-cardiac patients with a compromised immune system may
• “Prophylaxis may prevent an exceedingly small number be at risk for complications of bacteremia and distant site
of cases of IE if any, in individuals who undergo a infection following invasive dental procedures. Existing evi-
dental, GI tract, or GU tract procedure. dence does not support the extensive use of antibiotic prophy-
• The risk of antibiotic-associated adverse events exceeds laxis; prophylaxis should be limited to immunocompromised
the benefit, if any, from prophylactic antibiotic therapy. patients and those at high risk.19 Consultation with the
• Maintenance of optimal oral health and hygiene may patient’s physician is recommended for management of patients
reduce the incidence of bacteremia from daily activities with a compromised immune system. Although there is not
and is more important than prophylactic antibiotics enough data to support its use, high risk patients who should
for a dental procedure to reduce the risk of IE.”3 be considered for use of prophylaxis includes, but is not
limited to, those with13,14,25:
The AHA guidelines focus on antibiotic prophylaxis prior 1. Immunosuppression* secondary to:
to certain dental procedures for patients in the highest risk a. human immunodeficiency virus (HIV);
group (See Table 1).3,4,6 Globally, there is still a lack of con- b. severe combined immunodeficiency (SCIDS);
sensus with regards to the benefit of antibiotic prophylaxis c. neutropenia;
for prevention of infective endocarditis. Since the change in d. cancer chemotherapy; or
recommendations, the rate and incidence of IE have been low.4 e. hematopoietic stem cell or solid organ transplantation.
Children with cyanosis with specific periodontal concerns 2. History of head and neck radiotherapy.
may have an increased risk of IE, which makes optimum 3. Autoimmune disease (e.g., juvenile arthritis, systemic
oral hygiene very important.3,4,22 At-risk patients with poor lupus erythematosus).
oral hygiene and gingival bleeding after routine activities
(e.g., toothbrushing) have shown an increased incidence of * Discussion of antibiotic prophylaxis for patients receiving immunosuppressive
bacteremia as a measure for risk of IE.3,22,23 The focus should therapy and/or radiation therapy appears in a separate AAPD document.26

Table 1. CARDIAC CONDITIONS ASSOCIATED WITH THE HIGHEST RISK OF ADVERSE

OUTCOME FROM ENDOCARDITIS FOR WHICH PROPHYLAXIS WITH DENTAL
PROCEDURES IS REASONABLE
Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
Previous infective endocarditis
Congenital heart disease (CHD)*
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired congenital heart defect with prosthetic material or device, whether placed by
surgery or by catheter intervention, during the first six months after the procedure †
Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or
prosthetic device (which inhibit endothelialization)
Cardiac transplantation recipients who develop cardiac valvulopathy
* Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
† Prophylaxis is reasonable because endothelialization of prosthetic material occurs within six months after the procedure.
Reprinted with permission. Circulation. 2007;116:1736-1754. ©2007, American Heart Association, Inc.2
Table 2. DENTAL PROCEDURES FOR WHICH ENDOCARDITIS PROPHYLAXIS IS REASONABLE

FOR PATIENTS IN TABLE 1
All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or
perforation of the oral mucosa **
* The following procedures and events do not need prophylaxis: routine anesthetic injections through
non-infected tissue, taking dental radiographs, placement of removable prosthodontic or orthodontic
appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of deciduous
teeth, and bleeding from trauma to the lips or oral mucosa.
Table 3. REGIMENS FOR A DENTAL PROCEDURE
Regimen: Single Dose 30 to 60 min Before Procedure
Situation Agent Adults Children
Oral Amoxicillin 2g 50 mg/kg
Ampicillin 2 g IM or IV 50 mg/kg IM or IV
Unable to take oral medication OR
Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV
†
Cephalexin* 2g 50 mg/kg
Allergic to penicillins or OR
ampicillin—oral Clindamycin 600 mg 20 mg/kg
OR
Azithromycin or clarithromycin 500 mg 15 mg/kg
†
Allergic to penicillin or ampicillin Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV
and unable to take oral OR
medication Clindamycin 600 mg IM or IV 20 mg/kg IM or IV
IM indicates intramuscular; IV, intravenous.

* Or other first-or second-generation oral cephalosporin in equivalent adult or pediatric dosage.
† Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with
penicillins or ampicillin.

Table 4. MANAGEMENT OF PATIENTS WITH PROSTHETIC JOINTS UNDERGOING DENTAL PROCEDURES 5
Reprinted with permission. Copyright ©2015, American Dental Association. J Am Dent Assoc 2015;146(1):11-16.e8.
Publisher by Elsevier Inc. All right reserved. “www.ada.org”.
4. Sickle cell anemia.27 antibiotic prophylaxis. 25,31 Consultation with the child’s
5. Asplenism or status post splenectomy. physician is recommended for management of patients with
6. Chronic high dose steroid usage. vascular shunts.
7. Uncontrolled diabetes mellitus.
8. Bisphosphenate therapy.28,29 Patients with prosthetic joints
9. Hemodialysis. For patients with a history of total joint arthroplasty, deep
hematogenous infections can lead to life threatening com-
Patients with shunts, indwelling vascular catheters, or plications such as a loss of the prosthetic joint or even increased
medical devices morbidity and mortality.32,33 Given the increasing risk of de-
The AHA recommends that antibiotic prophylaxis for non- veloping antibiotic resistance and adverse reactions, antibiotic
valvular devices, including indwelling vascular catheters (e.g., prophylaxis prior to dental procedures is not recommended in
central lines) and cardiovascular implantable electronic devices the prevention of prosthetic joint infections.5
(CIED), is indicated only at the time of placement of these Consultation with the child’s physician may be necessary
devices in order to prevent surgical site infection.23,25 The AHA for management of at-risk patients as well as patients with
found no convincing evidence that microorganisms associated other implanted devices (e.g., Harrington rods, external fixa-
with dental procedures cause infection of CIED and nonval- tion devices).25,32-35
vular devices at any time after implantation.23,25 The infections
occurring after device implantation most often are caused by References
Staphylococcus aureus and coagulase negative staphylococci or 1. American Academy of Pediatric Dentistry. Antibiotic
other microorganisms that are non-oral in origin but are asso- chemoprophylaxis for pediatric dental patients. Boston,
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Consultation with the child’s physician is recommended for 2. American Academy of Pediatric Dentistry. Antibiotic
management of patients with nonvalvular devices. prophylaxis for dental patients at risk for infection.
Ventriculoatrial (VA), ventriculocardiac (VC), or ventricu- Pediatr Dent 2014;36(special issue):287-92.
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bacteremia-induced infections due to their vascular access.25,31 fective endocarditis: Guidelines from the American Heart
In contrast, ventriculoperitoneal (VP) shunts do not involve Association—A Guideline From the American Heart
any vascular structures and, consequently, do not require Association Rheumatic Fever, Endocarditis and Kawasaki

Disease Committee, Council on Cardiovascular Disease 15. Watters W, Rethman MP, Hanson NB, et al. Prevention
in the Young, and the Council on Clinical Cardiology, of orthopaedic implant infection in patients undergoing
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ciplinary Working Group. Circulation 2007;116(15): 16. de Sa DD, Tleyieh IM, Anavekar NS, et al. Epidemio-
1736-54. E-published April 19, 2007. Available at: “http: logical trends of infective endocarditis: A population-
//circ.ahajournals.org/cgi/content/full/116/15/1736”. based study in Olmsted County, Minnesota. Mayo Clin
Accessed July 2, 2019. Erratum in Circulation 2007;116 Proc 2010;85(5):422-6. Erratum in Mayo Clin Proc
(15):e376-e7. 2010;85(8):722.
4. Baltimore RS, Gweitz M, Baddour LM, et al. Infective 17. Thornhill MH, Dayer MJ, Prendergast B, Baddour LM,
endocarditis in childhood: 2015 update: A scientific Jones S, Lockhart PB. Incidence and nature of adverse
statement from the American Heart Association. Circu- reactions to antibiotics used as endocarditis prophylaxis.
lation 2015;132(15):1487-515. J Antimicrob Chemother 2015;70(8):2382-8.
5. Sollecito TP, Abt E, Lockhart PB, et al. The use of pro- 18. National Heart Foundation of New Zealand Advisory
phylactic antibiotics prior to dental procedures in patients Group. Guideline for the prevention of infective endo-
with prosthetic joints: Evidence-based clinical practice carditis associated with dental and other medical inter-
guideline for dental practitioners–A report of the ventions. Auckland: National Heart Foundation of New
American Dental Association Council on Scientific Affairs. Zealand. Available at: “http://www.ttophs.govt.nz/vdb/
J Am Dent Assoc 2015;146(1):11-6. document/312”. Accessed December 15, 2018. (Archived
6. Lockhart PB, Brennan MT, Kent ML, Norton JH, Weinrib
DA. Impact of amoxicillin prophylaxis on the incidence,
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YDlg2r”)
nature, and duration of bacteremia in children after 19. Habib G, Hoen B, Tornos P, et al. Guidelines on the pre-
intubation and dental procedures. Circulation 2004;109 vention, diagnosis, and treatment of infective endocarditis
(23):2878-84. (new version 2009): The Task Force on the Prevention,
7. Roberts GJ, Jaffrey EC, Spract DA, Petrie A, Greville C, Diagnosis, and Treatment of Infective Endocarditis of
Wilson M. Duration, prevalence and intensity of the European Society of Cardiology (ESC). Eur Heart J
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2006;92(9):1274-7. 20. National Institute for Health and Care Excellence. Con-
8. Daly CG. Antibiotic prophylaxis for dental procedures. text In: Prophylaxis against infective endocarditis:
Aust Prescr 2017;40(5):184-8. Antimicrobial prophylaxis against infective endocarditis
9. Fluent MT, Jacobsen PL, Hicks LA. Considerations for in adults and children undergoing interventional proce-
responsible antibiotic use in dentistry. J Am Dent Assoc dures. London: NICE. Available at: “https://www.nice.
2016;147(8):683-6. org.uk/guidance/cg64/chapter/Recommendations”.
10. Dajani AS, Taubert KA, Wilson W, et al. Prevention of
bacterial endocarditis: Recommendations by the American
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Heart Association. JAMA 1997;227(22):1794-801. 21. Lockhart PB, Brennan MT, Sasser HC, Fox PC, Paster BJ,
11. Centers for Disease Control and Prevention. Antibiotic/ Bahrani-Mougeot FK. Bacteremia associated with tooth-
Antimicrobial resistance. About antimicrobial resistance: brushing and dental extraction. Circulation 2008;117(24):
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779R5H5EJ”)
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and Adam’s Heart Disease in Infants, Children, and
12. Glenny AM, Oliver R, Roberts GJ, Hooper L, Worthington Adolescents: Including the Fetus and Young Adult, 8th
HV. Antibiotics for the prophylaxis of bacterial endocar- ed. Philadelphia, Pa.: Lippincott Williams & Wilkins;
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(10):CD003813. Available at: “https://doi-org.proxy. 23. Baddour LM, Epstein AE, Erickson CC, et al. Update on
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13pub4”. and their management. Circulation 2010;121(3):458-77.
13. Cahill TJ, Dayer M, Prendergast B, Thornhill M. Do 24. Lick SD, Edozie SN, Woodside KJ, Conti VR. Strepto-
patients at risk of infective endocarditis need antibiotics coccus viridans endocarditis from tongue piercing. J
before dental procedures? BMJ 2017;358:j3942. Emerg Med 2005;29(1):57-9.
14. Cahill TJ, Harrison JL, Jewell P, et al. Antibiotic prophy- 25. Lockhart PB, Loven B, Brennan MT, Fox PC. The evidence
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meta-analysis. Heart 2017;103(12):937-44. practice. J Am Dent Assoc 2007;138(4):458-74.

26. American Academy of Pediatric Dentistry. Dental manage- 31. Baddour LM, Bettman MA, Bolger AF, Bolger A, Ferrieri
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therapy and/or radiation therapy. Pediatr Dent 2018;40 Circulation 2003;108(16):2015-31.
(6):392-400. 32. Aminoshariae A, Kulild J. Premedication of patients
27. Tate AR, Norris CK, Minniti CP. Antibiotic prophylaxis undergoing dental procedures causing bacteremia after
for children with sickle cell disease: A survey of pediatric total joint arthroplasty. J Endod 2010;36(6):974-7.
dentistry residency program directors and pediatric 33. Rethman MP, Watters W 3rd, Abt E, et al. The American
hematologists. Pediatr Dent 2006;28(3):332-5. Academy of Orthopedic Surgeons and the American
28. Montefusco V, Gay F, Spina F, et al. Antibiotic prophy- Dental Association clinical practice guideline on the
laxis before dental procedures may reduce the incidence prevention of orthopaedic implant infection in patients
of osteonecrosis of the jaw in patients with multiple undergoing dental procedures. J Bone Joint Surg 2013;
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2008;49(11):2156-62. 34. Berbari EF, Osmon DR, Carr A, et al. Dental procedures
29. Rogers SN, Hung J, Barber AJ, Lowe D. A survey of as risk factors for prosthetic hip or knee infection: A
consultant members of the British Association of Oral hospital-based prospective case-control study. Clin
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Surg 2009;47(8):598-601. 35. Little JW, Jacobson JJ, Lockhart PB, American Academy
30. Hong CHL, Allred R, Napenas JJ, Brennan MT, Baddour of Oral Medicine. The dental treatment of patients with
LM, Lockhart PB. Antibiotic prophylaxis for dental joint replacements: A position paper from the American
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infections. Am J Med 2010;123(12):1128-33. (6):667-71.

BEST PRACTICES: IMMUNOSUPPRESSIVE AND/OR RADIATION THERAPY
Dental Management of Pediatric Patients Receiving

Immunosuppressive Therapy and /or Radiation
Therapy
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Dental man-
2018 agement of pediatric patients receiving immunosuppressive therapy
and/or radiation therapy. The Reference Manual of Pediatric Dentistry.
Purpose care, oral health, pediatric dentistry, practice guideline; field:

The American Academy of Pediatric Dentistry (AAPD) all; limits: within the last 10 years, humans, English, birth
recognizes that the pediatric dental professional plays an im- through age 18. Two thousand sixty-five articles matched
portant role in the diagnosis, prevention, stabilization, and these criteria. Ninety-five papers were chosen for review from
treatment of oral and dental problems that can compromise this list and from the references within selected articles. When
the child’s quality of life before, during, and after immuno- data did not appear sufficient or were inconclusive, recommen-
suppressive therapy which lowers the body’s normal immune dations were based upon expert and/or consensus opinion by
response. This can be deliberate as in lowering the immune experienced researchers and clinicians.
response to prevent the rejection of an organ or hematopoietic
cell transplant* (HCT), or it can be incidental as in a side effect Background
of chemotherapy, radiation therapy, or HCT conditioning. A multidisciplinary approach involving physicians, nurses,
Dental intervention with certain modifications must be done dentists, social workers, dieticians, and other related health
promptly and efficiently, with attention to the patient’s medical professionals is essential in caring for the child before, during
history, treatment protocol, and health status. and after any immunosuppressive therapy.1,2 Oral and asso-
Immunosuppressive therapy may cause many acute and ciated systemic complications that may occur as a sequelae
long-term side effects in the oral cavity. Furthermore, any of immunosuppressive therapy include pain, mucositis, oral
existing or potential sources of oral/dental infections and/or ulcerations, bleeding, taste dysfunction, secondary infections
soft tissue trauma can compromise the medical treatment, (e.g., candidiasis, herpes simplex virus), dental caries, salivary
leading to morbidity, mortality, and higher hospitalization gland dysfunction (e.g., xerostomia), neurotoxicity, mucosal
costs. It is imperative that the pediatric dentist be familiar fibrosis, gingival hypertrophy, post-radiation osteonecrosis,
with the patient’s medical history as well as oral manifestations bisphosphonate-related osteonecrosis, soft tissue necrosis, tem-
of the underlying condition poromandibular dysfunction (e.g., trismus), craniofacial and
dental developmental anomalies, and oral graft versus host
Methods disease (GVHD).1,3,4
Developed by the Clinical Affairs Committee as Management All patients undergoing immunosuppressive therapy should
of Pediatric Dental Patients Receiving Chemotherapy and/or have an oral examination prior to initiation of treatment.1,2
Radiation and adopted in 1986, this document was last Prevention and treatment of pre-existing or concomitant oral
revised in 2013. The revision by the Council of Clinical Affairs disease is essential to minimize complications in this popu-
included a new literature search of the PubMed /MEDLINE ® lation.5 The key to success in maintaining a healthy oral cavity
during therapy is patient compliance. The child and the parents
database using the terms: pediatric cancer, pediatric oncology,
hematopoietic cell transplantation, bone marrow transplanta- should be educated regarding the possible acute side effects
tion, immunosuppressive therapy, mucositis, stomatitis, chemo-
therapy, radiotherapy, acute effects, long-term effects, dental
ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. ANC: Absolute neu-
* The term HCT is also referred to as hematopoietic stem cell transplantation trophil count. BRONJ: Bisphosphonate-related osteonecrosis of the
(HSCT). jaw. CBC: Complete blood count. GVHD: Graft versus host disease.
HCT: Hematopoietic cell transplantation. LLLT: Low-level laser
therapy. MASCC / ISOO: The Multinational Association of Supportive
KEYWORDS: Hematopoietic Stem Cell Transplantation (HCT), Low-level Laser Care in Cancer/ International Society of Oral Oncology. /mm3: per
Therapy (LLLT), Oral Mucositis (OM), Radiation Therapy, Chemotherapy, cubic milimeter.
Pediatric Patient, Immunosuppressed Patient Hematologic Considerations.

and the long-term sequelae of immunosuppressive therapies Preventive strategies

in the oral cavity.3,5-9 Every patient should be managed on an Oral hygiene: Oral hygiene includes brushing of the teeth
individual basis; consultations with the patient’s physicians and tongue two to three times daily with regular soft nylon
and, when appropriate, other dental specialists should be brush or electric toothbrush, regardless of the hematological
sought before dental care is instituted.7 status. 7,8,11,12 Ultrasonic brushes and dental floss should be
allowed only if the patient is properly trained.8 If capable,
Recommendations the patient’s teeth should be gently flossed daily. If pain or
Dental and oral care before the initiation of immunosup- excessive bleeding occurs, the patient should avoid the affected
pressive therapy area, but floss the other teeth.1 Patients with poor oral hygiene
Objectives and/or periodontal disease may use chlorhexidine rinses
The objectives of a dental/oral examination before therapy daily until the tissue health improves or mucositis develops.13
starts are three-fold:9 The high alcohol content of commercially-available chlorhex-
• to identify and stabilize or eliminate existing and poten- idine mouthwash may cause discomfort and dehydrate the
tial sources of infection and local irritants in the oral tissues in patients with mucositis; thus, an alcohol-free
cavity—without needlessly delaying the treatment or chlorhexidine solution is indicated in this situation.
inducing complications.
• to communicate with the medical team regarding the Diet: Dental practitioners should discuss the importance of a
patient’s oral health status, plan, and timing of treatment. healthy diet to maintain nutritional status with an emphasis on
• to educate the patient and parents about the importance foods that do not promote caries. Patients and parents should
of optimal oral care in order to minimize oral problems/ be advised about the high cariogenic potential of dietary
discomfort before, during, and after treatment and about supplements rich in carbohydrates and oral pediatric med-
the possible acute and long-term effects of the therapy ications rich in sucrose.6 They should also be instructed that
in the oral cavity and the craniofacial complex. sharp, crunchy, spicy, and highly acidic foods and alcohol
should be avoided during chemotherapy, radiation, and HCT.1
Initial evaluation
Medical history review: should include, but not be limited to, Fluoride: Preventive measures include the use of fluoridated
disease/condition (type, stage, prognosis), treatment proto- toothpaste, fluoride supplements if indicated, neutral fluoride
col (conditioning regimen, surgery, chemotherapy, radiation, gels/rinses, or applications of fluoride varnish for patients at
transplant), medications (including bisphosphonates), allergies, risk for caries and/or xerostomia.6,8 A brush-on technique is
surgeries, secondary medical diagnoses, hematological status convenient and may increase the likelihood of patient com-
(complete blood count [CBC]), coagulation status, immuno- pliance with topical fluoride therapy.8
suppression status, presence of an indwelling venous access
line, and contact of medical team/primary care physician(s).1 Lip care: Lanolin-based creams and ointments are more
For HCT patients, include type of transplant, HCT source effective in moisturizing and protecting against damage than
(i.e., bone marrow, peripheral stem cells, cord blood stem petrolatum-based products.8
cells), matching status, donor, conditioning protocol, expected
date of transplant, and GVHD prophylaxis. Patients with a Trismus prevention/treatment: Patients who receive radiation
compromised immune system may not be able to tolerate a therapy to the masticatory muscles may develop trismus.
transient bacteremia following invasive dental procedures. Thus, daily oral stretching exercises/physical therapy should
The decision regarding the need for antibiotic prophylaxis for start before radiation is initiated and continue throughout
dental procedures should be made in consultation with the treatment.7,14
child’s physician. Unless advised otherwise by the physician,
the American Heart Association’s standard regimen to prevent Reduction of radiation to healthy oral tissues: In cases of
endocarditis is an accepted option.2,10 radiation to the head and neck, the use of lead-lined stents,
prostheses, and shields, as well as salivary gland sparing
Dental history review: includes information such as fluo- techniques (e.g., three-dimensional conformal or intensity
ride exposure, habits, trauma, symptomatic teeth, previous modulated radiotherapy, concomitant cytoprotectants, surgical
care, preventive practices, oral hygiene, and diet assessment. transfer of salivary glands), should be discussed with the
radiation oncologist.
Oral/dental assessment: should include thorough head,
neck, and intraoral examinations, oral hygiene assessment and Education: Patient and parent education includes the im-
training, and radiographic evaluation based on history and portance of optimal oral care in order to minimize oral
clinical findings. problems and discomfort before, during, and after treatment
and the possible acute and long-term effects of the therapy
in the craniofacial complex.1

Dental care carious lesions should be treated first.8 Incipient to small

Hematological considerations: carious lesions may be treated with fluoride, silver
• Absolute neutrophil count (ANC): diamine fluoride, and/or sealants until definitive care can
— >2,000 per cubic millimeter (/mm3): no need for be accomplished.7 Some patients requiring an organ
antibiotic prophylaxis;1,14 transplant will be best able to tolerate dental care at least
— 1000 to 2000/mm3: Use clinical judgment1 based on three months after transplant when overall health im-
the patient’s health status and planned procedures. proves.2 It is important for the practitioner to be aware
Some authors1,7 suggest that antibiotic coverage (dosed that the signs and symptoms of periodontal disease may
per AHA recommendations13) may be prescribed when be decreased in immunosuppressed patients.7
the ANC is between 1,000 and 2,000/mm3. If infec- • Pulp therapy in primary teeth: Few studies have eval-
tion is present or unclear, more aggressive antibiotic uated the safety of performing pulp therapy in primary
therapy may be indicated and should be discussed teeth prior to the initiation of chemotherapy and/or
with the medical team; and radiotherapy. Many clinicians choose to provide a more
— <1,000/mm3: defer elective dental care.4 In dental definitive treatment in the form of extraction because
emergency cases, discuss antibiotic coverage (antibiotic pulpal/periapical/furcal infections during immunosup-
prophylaxis versus antibiotic coverage for a period pression periods can become life-threatening.7,8 Teeth that
of time) with medical team before proceeding with already have been treated pulpally and are clinically and
treatment. The patient may need hospitalization for radiographically sound should be monitored periodically
dental management. for signs of internal resorption or failure due to pulpal/
• Platelet count7: periapical/furcal infections.
— >75,000/mm3: no additional support needed; • Endodontic treatment in permanent teeth: Symptomatic
— 40,000 to 75,000/mm3: platelet transfusions may be non-vital permanent teeth should receive root canal
considered pre- and 24 hours post-operatively. Local- treatment at least one week before initiation of therapy
ized procedures to manage prolonged bleeding may to allow sufficient time to assess treatment success before
include sutures, hemostatic agents, pressure packs, and/ the chemotherapy.4,7,14 If that is not possible, extraction
or gelatin foams; and is indicated. Extraction is also the treatment of choice
— <40,000/mm3: defer care. In dental emergency cases, for teeth that cannot be treated by definitive endodontic
contact the patient’s physician to discuss supportive treatment in a single visit. In that case, the extraction
measures (e.g., platelet transfusions, bleeding control, should be followed by antibiotic therapy (penicillin or,
hospital admission and care) before proceeding. In for penicillin-allergic patients, clindamycin) for about
addition, localized procedures (e.g., microfibrillar col- one week.7,14 Endodontic treatment of asymptomatic
lagen, topical thrombin) and additional medications non-vital permanent teeth may be delayed until the
as recommended by the hematologist/oncologist (e.g., hematological status of the patient is stable.4,14 It is im-
aminocaproic acid, tranexamic acid) may help control portant that the etiology of periapical lesions associated
bleeding.1 with previously endodontically treated teeth be deter-
• Other coagulation tests may be in order for individual mined because they can be due to a number of factors
patients. including pulpal infections, inflammatory reactions,
apical scars, cysts, and malignancy.8 If a periapical lesion
Dental procedures: is associated with an endodontically treated tooth and no
• Ideally, all dental care should be completed before im- signs or symptoms of infection are present, there is no
munosuppressive therapy is initiated. When that is not need for retreatment or extraction since the radiolucency
feasible, temporary restorations may be placed and non- likely is due to an apical scar.15
acute dental treatment may be delayed until the patient’s • Orthodontic appliances and space maintainers: Poorly-
hematological status is stable.1,7 The patient’s blood fitting appliances can abrade oral mucosa and increase the
counts normally start falling five to seven days after the risk of microbial invasion into deeper tissues.7 Appliances
beginning of treatment cycle, staying low for approxi- should be removed if the patient has poor oral hygiene
mately 14 to 21 days, before rising again to normal levels and/or the treatment protocol or HCT conditioning
for a few days until the next cycle begins. regimen carries a risk for the development of moderate
• Prioritizing procedures: When all dental needs cannot to severe mucositis.4 Simple appliances (e.g., band and
be treated before therapy is initiated, priorities should loops, fixed lower lingual arches) that are not irritating
be infections, extractions, periodontal care (e.g., scaling, to the soft tissues may be left in place in patients who
prophylaxis), and sources of tissue irritation before the present good oral hygiene.4,8 Removable appliances and
treatment of carious teeth, root canal therapy for perma- retainers that fit well may be worn as long as tolerated
nent teeth, and replacement of faulty restorations.4,14 by the patient who maintains good oral care.7,8 Patients
Pain and the risk for pulpal infection determine which should be instructed to clean their appliance daily and

routinely clean appliance cases with an antimicrobial Some practitioners prefer to extract all third molars
solution to prevent contamination and reduce the risk of that are not fully erupted, particularly prior to HCT,
appliance-associated oral infections.7 Consider removing while others favor a more conservative approach, recom-
orthodontic bands or adjusting prosthesis if a patient is mending extraction of third molars at risk for pulpal
expected to receive cyclosporine or other drugs known infection or those associated with significant pathology,
to cause gingival hyperplasia. If band removal is not infection, periodontal disease, or pericoronitis or if the
possible, vinyl mouth guards or orthodontic wax should tooth is malpositioned or non-functional.8,19,20
be used to decrease tissue trauma.8
• Periodontal considerations: Partially erupted molars can Communication:
become a source of infection because of pericoronitis. The It is vital that the dentist communicate the comprehensive
overlying gingival tissue should be excised if the dentist oral care plan with the medical team. Information to be
believes it is a potential risk and if the hematological shared includes the severity of dental caries (number of teeth
status permits.8,14 Patients should have a periodontal as- involved and which teeth need immediate treatment), endo-
sessment and appropriate therapy prior to receiving bis- dontic needs (pulpal versus periapical infection), periodontal
phosphonates as part of cancer treatment.16-18 Extraction status, number of teeth requiring extraction, soft tissue path-
is the treatment of choice for teeth with a poor prognosis ology, and any other urgent care needed. Furthermore, it is
that cannot be treated by definitive periodontal therapy. important for the dentist to discuss with the medical team
If the patient has had bisphosphonates and an invasive how much time is needed for the stabilization of oral disease
periodontal procedure is indicated, risks must be discussed as this will also affect the timing of the treatment or
with the patient, parents, and physicians prior to the conditioning protocols.1
procedure.
• Extractions: There are no clear recommendations for the Dental and oral care during immunosupression periods
use of antibiotics for extractions.4 Recommendations Preventive strategies
generally have been empiric or based on anecdotal ex- Oral hygiene: Intensive oral care is of paramount importance
perience. Surgical procedures must be as atraumatic as because it reduces the risk of developing moderate/severe mu-
possible, with no sharp bony edges remaining and cositis without causing an increase in septicemia and infections
satisfactory closure of the wounds.7,8,14 If there is in the oral cavity.1,3,5-8,11,14,21 Thrombocytopenia should not be
documented infection associated with the tooth, anti- the sole determinant of oral hygiene as patients are able to
biotics (ideally chosen with the benefit of sensitivity brush without bleeding at widely different levels of platelet
testing) should be administered for about one week.7,8,14 count.8 Patients should use a soft nylon brush two to three
To minimize the risk of development of osteone- times daily and replace it on a regular (every two to three
crosis, osteoradionecrosis, or bisphosphonate-related months) basis.8,11 Fluoridated toothpaste may be used but,
osteonecrosis of the jaw (BRONJ), patients who will if the patient does not tolerate it during periods of mucositis
receive radiation to the jaws or bisphosphonate treatment due to oral burning or stinging sensations, it may be discon-
as part of the cancer therapy must have all oral surgical tinued and the patient should switch to mild-flavored non-
procedures completed before those measures are insti- fluoridated toothpaste. If moderate to severe mucositis
tuted.16-18 If the patient has received bisphosphonates develops and the patient cannot tolerate a regular soft nylon
or radiation to the jaws and an oral surgical procedure toothbrush or an end-tufted brush, foam brushes or super
is necessary, risks must be discussed with the patient, soft brushes soaked in chlorhexidine may be used.9 Other-
parents, and physician prior to the procedure. In patients wise, foam or super soft brushes should be discouraged
undergoing long-term potent, high-dose intravenous because they do not allow for effective cleaning. The use of a
bisphosphonates, there is an increased risk of BRONJ regular brush should be resumed as soon as the mucositis
after a tooth extraction or with periodontal disease,16-18 improves.8,11 Brushes should be air-dried between uses.8
although most of the evidence has been described in the Electric or ultrasonic brushes are acceptable if the patient is
adult population.17 Patients with a high risk of BRONJ capable of using them without causing trauma and irrita-
are best managed by a dental specialist in coordination tion. If patients are skilled at flossing without traumatizing
with the medical team in the hospital setting. the tissues, it is reasonable to continue flossing throughout
Loose primary teeth should be allowed to exfoliate treatment. Toothpicks and water irrigation devices should not
naturally. Nonrestorable teeth, root tips, teeth with perio- be used when the patient is pancytopenic to avoid tissue
dontal pockets greater than six millimeters, symptomatic trauma.8,10
impacted teeth, and teeth exhibiting acute infections,
significant bone loss, involvement of the furcation, or Dental care
mobility should be removed ideally two weeks (or at During immunosuppression, elective dental care should not
least seven to 10 days) before therapy is initiated to be provided. If a dental emergency arises, the treatment plan
allow adequate healing.7,8,14 should be discussed with the patient’s physician who will

make recommendations for supportive medical therapies readily available, but further research is needed to confirm the
(e.g., antibiotics, platelet transfusions, analgesia). The patient effectiveness of oral cryotherapy in pediatric oncology.27
should be seen every six months (or in shorter intervals if Studies on the use of chlorhexidine for mucositis have
there is a risk of xerostomia, caries, trismus, and/or chronic given conflicting results. Most studies have not demonstrated
oral GVHD) for an oral health evaluation during treatment, a prophylactic impact or a reduction in the severity of
in times of stable hematological status and always after review- mucositis, although reduced colonization of candidal species
ing the medical history. has been shown. 14,28,29 Chlorhexidine is no longer recom-
mended for preventing oral mucositis in patients undergoing
Management of oral conditions related to immunosuppressive radiotherapy.11,22,30
therapies Patient-controlled analgesia has been helpful in relieving
Mucositis: The Multinational Association of Supportive Care pain associated with mucositis, reducing the requirement for
in Cancer/International Society of Oral Oncology (MASCC/ oral analgesics. There is no significant evidence of the effec-
ISOO) has published guidelines for treatment of mucositis.11,22 tiveness of mixtures containing topical anesthetics (e.g.,
The most common prescriptions for management of mucositis Philadelphia mouthwash, magic mouthwash).22,30 The use of
include good oral hygiene, analgesics, non-medicated oral topical anesthetics has been suggested for pain management,11
rinses (e.g., 0.9 percent saline or sodium bicarbonate mouth although there are no studies available to assess the benefit
rinses four to six times/day), and parenteral nutrition as and potential for toxicity. Topical anesthetics only provide
needed. 1,11,21 Mucosal coating agents (e.g., Amphojel , ® short term pain relief. 11,30 Lidocaine use may obtund or
®
Kaopectate , hydroxypropylmethylcellulose) and film-forming diminish taste and the gag reflex30 and/or result in a burning
® ®
agents (e.g., Zilactin and Gelclair ) also have been suggested.1
Effective interventions for mucositis prevention include the
sensation, in addition to possible cardiovascular and central
nervous system effects.
use of palifermin, low-level laser therapy (LLLT), and cryo-
therapy. 22 The use of sucralfate, antimicrobial lozenges, Oral mucosal infections: The signs of inflammation and infec-
pentoxifylline, and granulocyte–macrophagecolony stimulating tion may be greatly diminished during neutropenic periods.
factor mouthwash for oral mucositis are not recommended.11,22 Thus, the clinical appearance of infections may differ signifi-
Palifermin (keratinocyte growth factor-1) is a drug approved cantly from the normal.14 Close monitoring of the oral cavity
by the U.S. Food and Drug Administration for the prevention allows for timely diagnosis and treatment of fungal, viral, and
and treatment of oral mucositis.23 It is recommended for mu- bacterial infections. Prophylactic nystatin is not effective for
cositis prophylaxis for patients undergoing conditioning with the prevention and/or treatment of fungal infections.7,31 Oral
high-dose chemotherapy and total body irradiation followed cultures and/or biopsies of all suspicious lesions should be
by HCT.22 Palifermin is believed to stimulate epithelial cell performed and prophylactic medications should be initiated
reproduction, growth, and development so that mucosal cells until more specific therapy can be prescribed.1,7,8,14
damaged by chemotherapy and radiation are replaced quickly,
accelerating the healing process.23 Oral bleeding: Oral bleeding occurs due to thrombocytopenia,
The current MASCC/ISOO guidelines support the use of disturbance of coagulation factors, and/or damaged vascular
low-level laser therapy to prevent oral mucositis for patients integrity. Management should consist of local approaches
undergoing HSC conditioning with high-dose chemotherapy (e.g., pressure packs, antifibrinolytic rinses or topical agents,
with or without total body irradiation as well as patients un- gelatin sponges) and systemic measures (e.g., platelet trans-
dergoing radiation treatment for head and neck cancer.22 LLLT fusions, aminocaproic acid).7,8,14
can decrease pain and the duration and severity of chemo-
therapy-induced mucositis in children.24-26 LLLT may not be Dental sensitivity/pain: Tooth sensitivity could be related to
available at all cancer treatment centers due to the cost of the decreased secretion of saliva during radiation therapy and the
equipment and the need for trained personnel. Appropriate lowered salivary pH.7,8,14 Patients who are using plant alkaloid
protocol must be followed when using LLLT to prevent con- chemotherapeutic agents (e.g., vincristine, vinblastine) may
tamination and occupational risks to the child and dental present with deep, constant pain (affecting the mandibular
team. molars with greater frequency) in the absence of odontogenic
Oral cryotherapy, the cooling of intraoral tissue with ice pathology. The pain usually is transient and generally subsides
during chemotherapy treatment, is recommended as mu- shortly after dose reduction and/or cessation of chemo-
cositis prophylaxis for patients receiving bolus infusion of therapy.7,8,14
chemotherapy drugs with short half-lives.22,27 This includes
patients treated with fluorouracil as well as patients receiving Xerostomia: Sugar-free chewing gum or candy, sucking tablets,
high-dose melphalan as conditioning for HCT.22 Oral cryo- special dentifrices for oral dryness, saliva substitutes, frequent
therapy reduces blood flow to the mouth by narrowing the sipping of water, alcohol-free oral rinses, and/or oral moistur-
blood vessels, limiting the amount of chemotherapy drugs izers are recommended.8,32 Placing a humidifier by bedside at
delivered to the tissues. Cryotherapy is inexpensive and night may be useful.14 Saliva stimulating drugs are not

approved for use in children. Fluoride rinses and gels are until immunological recovery has occurred, at least 100 days
recommended highly for caries prevention in these patients. following HCT, or longer if chronic GVHD or other com-
plications are present.7,8 Therefore, all dental treatment should
Trismus: Daily oral stretching exercises/physical therapy must be completed before the patient becomes immunosuppressed.
continue during radiation treatment. Management of trismus
may include prosthetic aids to reduce the severity of fibrosis, Phase II: Conditioning neutropenic phase
trigger-point injections, analgesics, muscle relaxants, and other In this phase, which encompasses the day the patient is ad-
pain management strategies.7,33 mitted to the hospital to begin the transplant conditioning
to 30 days post-HCT, the oral complications are related to the
Hematopoietic cell transplantation conditioning regimen and supportive medical therapies.8
Hematopoietic cell transplantation can be used in children Mucositis, xerostomia, oral pain, hemorrhage, opportunistic
to treat malignancies and hematologic disorders, as well as infections, taste dysfunction, neurotoxicity (including dental
certain metabolic syndromes. Examples include:34 pain, muscle tremors), and temporomandibular dysfunction
• malignant disorders treated with autologous HCT (including jaw pain, headache, joint pain) may be seen,
– brain tumors. typically with a high prevalence and severity of oral complica-
– Ewing sarcoma. tions.1 Oral mucositis usually begins seven to 10 days after
– germ cell tumors. initiation of conditioning, and symptoms continue approxi-
– Hodgkin lymphoma. mately two weeks after the end of conditioning.1 Among
– leukemia. allogeneic transplant patients, hyperacute GVHD can occur,
– neuroblastoma. causing more severe inflammation and severe mucositis
– non-Hodgkin lymphoma. symptoms, although its clinical presentation is difficult to
– Wilms tumor. diagnose.1 The patient should be followed closely to monitor
• malignant disorders treated with allogenic HCT and manage the oral changes and to reinforce the importance
– acute lymphocytic leukemia. of optimal oral care. Dental procedures usually are not
– acute myeloid leukemia. allowed in this phase due to the patient’s severe
– high-risk solid tumors. immunosuppression. If emergency treatment is necessary, the
– juvenile myelomonocytic leukemia. dentist should consult and coordinate with the attending
– myelodysplastic syndrome. transplant team.
• non-malignant disorders treated with allogenic HCT
– bone marrow failure syndromes. Phase III: Engraftment to hematopoietic recovery
– chronic granulomatous disease. The intensity and severity of complications begin to decrease
– Fanconi anemia. normally three to four weeks after transplantation. Oral
– metabolic storage disorders. fungal infections and herpes simplex virus infection are most
– osteopetrosis. notable.1 Acute GVHD can become a concern for allogeneic
– severe aplastic anemia. graft recipients. Xerostomia, hemorrhage, neurotoxicity, tem-
– sickle cell anemia. poromandibular dysfunction, and granulomas/papillomas
– thalessemia. sometimes are observed.1 A dental/oral examination should be
– Wiskott-Aldrich syndrome. performed and invasive dental procedures, including dental
Specific oral complications can be correlated with phases cleanings and soft tissue curettage, should be done only if
of HCT.1-8 authorized by the HCT team because of the patient’s conti-
nued immunosuppression.8 Patients should be encouraged to
Phase I: Preconditioning optimize oral hygiene and avoid a cariogenic diet. Attention to
The oral complications are related to the current systemic and xerostomia and oral GVHD manifestations is crucial. HCT
oral health, oral manifestations of the underlying condition, patients are particularly sensitive to intraoral thermal stimuli
and oral complications of recent medical therapy. Oral com- between two and four months post-transplant.8 The mecha-
plications observed include oral infections, gingival leukemic nism is not well understood, but the symptoms usually
infiltrates, bleeding, ulceration, and temporomandibular dys- resolve spontaneously within a few months. Topical application
function.1 Most of the principles of dental and oral care before of neutral fluoride or desensitizing toothpastes helps reduce
the transplant are similar to those discussed for pediatric the symptoms.8
immunosuppressive therapy.9 The two major differences in
HCT are: 1) the patient receives all the chemotherapy and/or Phase IV: Immune reconstitution/recovery from systemic toxicity
total body irradiation in just a few days before the transplant, After day 100 post-HCT, the oral complications predomin-
and 2) there will be prolonged immunosuppression following antly are related to the chronic toxicity associated with the
the transplant. Elective dentistry will need to be postponed conditioning regimen, including salivary dysfunction,

craniofacial growth abnormalities, late viral infections, oral used or will be given bisphosphonates in the future present a
chronic GVHD, and oral squamous cell carcinoma.1,8 Xerostomia challenge for orthodontic care. Although bisphosphonate
and relapse-related oral lesions also may be observed.1 Unless inhibition of tooth movement has been reported in animals,
the patient is neutropenic or with severe chronic GVHD, it has not been quantified for any dose or duration of therapy
mucosal bacterial infections are less frequently seen. Periodic in humans.36 Consultation with the patient’s parents and
dental examinations with radiographs can be performed, but physician regarding the risks and benefits of orthodontic care
invasive dental treatment should be avoided in patients with in this situation is recommended.
profound impairment of immune function.8 Consultation with
the patient’s physician and parents regarding the risks and Oral surgery: Consultation with an oral surgeon and/or
benefits of orthodontic care is recommended. periodontist and the patient’s physician is recommended for
non-elective oral surgical and invasive periodontal procedures
Dental and oral care after the immunosuppressive therapy in patients who have used or are using bisphosphonates or
is completed those who received radiation therapy to the jaws in order to
Objectives devise strategies to decrease the risk of osteonecrosis and
The objectives of a dental/oral examination after immuno- osteoradionecrosis, respectively.16-18 Elective invasive procedures
suppressive therapy ends are three-fold: should be avoided in these patients.37 Patients with a high risk
• to maintain optimal oral health. of BRONJ are best managed by in coordination with the
• to reinforce to the patient/parents the importance of oncology team in the hospital setting.
optimal oral and dental care for life.
• to address and/or treat any dental issues that may arise as Long-term concerns
a result of the long-term effects of immuno-suppressive Craniofacial, skeletal, and dental developmental issues are
therapy. some of the complications faced by survivors1,4,8 and usually
develop among children who were less than six years of age
Dental care at the time of their cancer therapy.4,8 Long term effects of
Periodic evaluation: The patient should be seen at least every immunosuppressive therapy may include tooth agenesis, mi-
six months (or in shorter intervals if issues such as chronic crodontia, crown disturbances (size, shape, enamel hypoplasia,
oral GVHD, xerostomia, or trismus are present). Patients pulp chamber anomalies), root disturbances (early apical
who have experienced moderate or severe mucositis and/or closure, blunting, changes in shape or length), reduced man-
chronic oral GVHD should be followed closely for malignant dibular length, reduced alveolar process height, and reduced
transformation of their oral mucosa (e.g., oral squamous cell vertical growth of the face.4 The severity of the dental de-
carcinoma).5,35 velopmental anomaly will depend on the age and stage of
development during exposure to cytotoxic agents or ionizing
Education: The importance of optimal oral and dental care radiation. Patients may experience permanent salivary gland
for life must be reinforced. It is also important to emphasize hypofunction/dysfunction or xerostomia.33 Relapse or sec-
the need for regular follow-ups with a dental professional, ondary malignancies can develop at this stage.1 Routine
especially for patients who are at risk for or have developed periodic examinations are necessary to provide comprehensive
GVHD and/or xerostomia and those who were younger than oral healthcare. Careful examination of extra-oral and intra-
six years of age during treatment due to potential dental de- oral tissues (including clinical, radiographic, and/or additional
velopmental problems. diagnostic examinations) are integral to diagnosing any
secondary malignancies in the head and neck region. Dental
Orthodontic treatment: Orthodontic care may start or resume treatment may require a multidisciplinary approach, involving
after completion of all therapy and after at least a two-year a variety of dental specialists to address the treatment needs
disease-free survival when the risk of relapse is decreased and of each individual. Consultation with the patient’s physician
the patient is no longer using immunosuppressive drugs.4 A is recommended if relapse or the patient’s immunologic status
thorough assessment of any dental developmental disturbances declines.
caused by the therapy must be performed before initiating
orthodontic treatment. The following strategies should be References
considered when providing orthodontic care for patients with
dental sequelae: (1) use appliances that minimize the risk of
®
1. National Cancer Institute. PDQ Oral Complications
of Chemotherapy and Head/Neck Radiation. Bethesda,
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massimo PS, eds. The Handbook of Pediatric Dentistry. 16. Saad F, Brown JE, Van Poznak C, et al. Incidence, risk
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BEST PRACTICES: RECORD KEEPING
Record-keeping
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Record-keeping.
2017 The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Purpose making based on signs and symptoms, administrative manage-

The American Academy of Pediatric Dentistry (AAPD) ment for patient education and recall, and electronic data
recognizes the patient record is an essential component of the interchange with other professional and third parties. The
delivery of competent and quality oral health care. It serves software must contain all the essential elements of a traditional
as an information source for the care provider and patient, as paper record. Daily back up of the office software system should
well as any authorized third party. This document will assist be performed and stored in an electronic data base that is
the practitioner in assimilating and maintaining a compre- retrievable by office personnel in the event that patient records
hensive, uniform, and organized record addressing patient are lost or damaged.
care. However, it is not intended to create a standard of care. The elements of record-keeping addressed in this docu-
ment are general charting considerations; initial patient record;
Methods components of a patient record; patient medical and dental
This best practice was developed by the Council on Clinical histories; comprehensive and limited clinical examinations;
Affairs and adopted in 2004. This document is a revision of treatment planning and informed consent; progress notes;
the previous version, last revised in 2012. This revision in- correspondence, consultations, and ancillary documents; and
cluded a new literature search of the PubMed /MEDLINE
®
database using the terms: dental record, electronic patient
confidential notes. Additionally, appendices to this guideline
illustrate items for consideration in the development of patient
record, problem-oriented dental record, medical history taking, medical and dental histories and examination forms. These
medical record, record keeping, and Health Insurance Port- lists, developed by experts in pediatric dentistry and offered to
ability and Accountability Act (HIPAA); fields: all; limits: facilitate excellence in practice, should be modified as needed
within the last 10 years, humans, and English. Papers for review by individual practitioners. These samples do not establish a
were chosen from this list and from the references within standard of care. In issuing this information, the AAPD is not
selected articles and dental textbooks. When data did not engaged in rendering legal or other professional advice. If such
appear sufficient or were inconclusive, recommendations were services are required, competent legal or other professional
based upon expert and/or consensus opinion by experienced counsel should be sought.
researchers and clinicians.
Recommendations
Background General charting considerations
The patient record provides all privileged parties with the The dental record must be authentic, accurate, legible, and
history and details of patient assessment and communications objective. Each patient should have an individual dental rec-
between dentist and patient, as well as specific treatment record. Chart entries should contain the initials or name of
ommendations, alternatives, risks, and care provided. The the individual making the note. Abbreviations should be
patient record is an important legal document in third party standardized for the practice. After data collection, a list is
relationships. Poor or inadequate documentation of patient compiled that includes medical considerations, psychological/
care consistently is reported as a major contributing factor in behavior constraints, and the oral health needs to be addressed.
unfavorable legal judgments against dentists.1 Therefore, the Problems are listed in order of importance in a standardized
AAPD recognizes that recommendation on record-keeping fashion making it less likely that an area might be overlooked.
may provide dentists the information needed to compile an The plan identifies a general course of treatment for each
accurate and complete patient chart that can be interpreted problem. This plan can result in the need for additional in-
by a knowledgeable third-party. formation, consultation with other practitioners, patient edu-
An electronic patient record is becoming more common- cation, and preventive strategies.
place, and perhaps will become mandatory.1-3 Health information
systems and electronic health records are being implemented as
a means to improve the quality and efficiency of health care.4 ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. HIPAA: Health Insur-
Advantages include quality assurance by allowing comparative
ance Portability and Accountability Act. TMD: Temporomandibular
analysis of groups of patients or providers, medical and dental disorder. TMJ: Temporomandibular joint.
history profiles for demographic data, support for decision

Initial patient record patient’s medical history, or if the dentist providing care is
The parent’s/patient’s initial contact with the dental practice, unfamiliar with the patient’s medical diagnosis, consultation
usually via telephone, allows both parties an opportunity to with the medical health care provider may be indicated.
address the patient’s primary oral health needs and to confirm Documentation of the patient’s medical history includes
the appropriateness of scheduling an appointment with that the following elements of information, with elaboration of
particular practitioner. During this conversation, the recep- positive findings:
tionist may record basic patient information such as: • medical conditions and/or illnesses;
• patient’s name, nickname, and date of birth. • name and, if available, telephone number of primary
• name, address, and telephone number of parent. and specialty medical care providers;
• name of referring party. • current therapies (e.g., physical, occupational, speech);
• significant medical history. • hospitalizations/surgeries;
• chief complaint. • anesthetic experiences;
• availability of medical/dental records (including • current medications;
radiographs) pertaining to patient’s condition. • allergies/reactions to medications;
• other allergies/sensitivities;
Such information constitutes the initial dental record. At • immunization status;
the first visit to the dental office, additional information would • review of systems;
be obtained and a permanent dental record developed. • family history; and
• social history.
Components of a patient record
The dental record must include each of the following specific Appendix I provides suggestions for specific information
components: that may be included in the written medical questionnaire or
• medical history; during discussions with the patient/parent. The history form
• dental history; should provide the parent/legal guardian additional space for
• clinical assessment; information regarding positive historical findings, as well any
• diagnosis; medical conditions not listed. There should be areas on the
• treatment recommendations; form indicating the date of completion, the signature of the
• progress notes; and person providing the history (along with his/her relationship
• acknowledgment of receipt of Notice of Privacy to the patient), and the signature of the staff member review-
Practices/HIPAA consent.5,6 ing the history with the parent/legal guardian. Records of
patients with significant medical conditions should be marked
When applicable, the following should be incorporated Medical Alert in a conspicuous yet confidential manner.
into the patient’s record as well:
• radiographic assessment; Supplemental history for infants/toddlers11,12
• caries risk assessment; The very young patient can present with unique develop-
• parental consent/patient assent; mental and social concerns that impact the health status of
• sedation/general anesthesia records; the oral cavity. Information regarding these considerations
• trauma records; may be collected via a supplemental history questionnaire for
• orthodontic records; infants/toddlers. Topics to be discussed may include a history
• consultations/referrals; of prematurity/perinatal complications, developmental consid-
• laboratory orders; erations, feeding and dietary practices, timing of first tooth
• test results; and appearance, and tooth brushing initiation and timing as well
• additional ancillary records. as toothpaste use. Assessment of developmental milestones
(e.g., gross/fine motor skills, language, social interactions) is
Medical history7-10 crucial for early recognition of potential delays and appropriate
An accurate, comprehensive, and up-to-date medical history is referral to therapeutic services.13 As a majority of infants and
necessary for correct diagnosis and effective treatment plan- toddlers of employed mothers receive childcare on a regular
ning. Familiarity with the patient’s medical history is essential basis from persons other than their parents,14 and because the
to decreasing the risk of aggravating a medical condition while primary caretaker influences the child’s risk for caries, the
rendering dental care. Additionally, a thorough history can aid questionnaire also should ascertain childcare arrangements.
the diagnosis of dental as well as medical conditions. The Data gathered from this questionnaire will benefit the clinical
practitioner, or staff under the supervision of the practitioner, examination, caries risk assessment, preventive homecare plan,
must obtain a medical history from the parent (if the patient and anticipatory guidance counseling. A sample form is avail-
is under the age of 18) before commencing patient care. able on the AAPD website at http://www.aapd.org/media/
When the parent cannot provide adequate details regarding a Policies_Guidelines/RS_MedHistoryForm.pdf.

Supplemental history for adolescents10,12 • TMJ assessment.

The adolescent can present particular psychosocial character- • intraoral soft tissue examination.
istics that impact the health status of the oral cavity, care • oral hygiene and periodontal health assessment.
seeking, and compliance. Integrating positive youth develop- • assessment of the developing occlusion.
ment8 into the practice, the practitioner should obtain addi- • intraoral hard tissue examination.
tional information confidentially from teenagers. Topics to be • radiographic assessment, if indicated.17
discussed may include nutritional and dietary considerations, • caries risk assessment.18
eating disorders, alcohol and substance abuse, tobacco usage, • assessed behavior of child.19
over-the-counter medications and supplements, and body art
(e.g., intra- and extra-oral piercings, tattoos), as well as the use Appendix III provides suggestions for specific information
of oral contraceptives and pregnancy for the female adolescent. that may be included in the oral examination.
A sample confidential history form is available on AAPD’s The dentist may employ additional diagnostic tools to
website at http://www.aapd.org/media/Policies_Guidelines/RS_ complete the oral health assessment. Such diagnostic aids may
MedHistoryForm.pdf. include electric or thermal pulp testing, photographs, labora-
tory tests, and study casts. The speech may be evaluated and
Medical update12 provide additional diagnostic information in children who are
At each patient visit, the history should be consulted and able to talk.
updated. Recent medical attention for illness or injury, newly
diagnosed medical conditions, and changes in medications Examinations of a limited nature
should be documented. A written update should be obtained If a patient is seen for limited care, a consultation, an emer-
at each recall visit. gency, or a second opinion, a medical and dental history must
be obtained, along with a hard and soft tissue examination as
Dental history 8,9,11,15 deemed necessary by the practitioner. The parent should be
A thorough dental history is essential to guide the practitioner’s informed of the limited nature of the treatment and counseled
clinical assessment, make an accurate diagnosis, and develop to seek routine comprehensive care. The AAPD’s Assessment
a comprehensive preventive and therapeutic program for each of Acute Traumatic Injuries form20 provides greater details
patient. The dental history should address the following: on diagnostic procedures and documentation for emergent
• chief complaint; traumatic injury care.
• previous dental experience;
• date of last dental visit/radiographs; Treatment recommendations and informed consent21
• oral hygiene practices; Once the clinician has obtained the medical and dental histo-
• fluoride use/exposure history; ries and evaluated the facts obtained during the diagnostic
• dietary habits (including bottle/no-spill training cup procedures, the diagnoses should be derived and a sequential
use in young children); prioritized treatment plan developed. The treatment plan
• oral habits; would include specific information regarding the nature of the
• sports activities; procedures/materials to be used, number of appointments/
• previous orofacial trauma; time frame needed to accomplish this care, behavior guidance
• temporomandibular joint (TMJ) history; techniques, and fee for proposed procedures. The dentist is
• family history of caries; and obligated to educate the parent on the need for and benefits
• social development. of the recommended care, as well as risks, alternatives, and
expectations if no intervention is provided. When deemed
Appendix II provides suggestions for specific information appropriate, the patient should be included in these discus-
that may be included in the written dental questionnaire or sions. The dentist should not attempt to decide what the
during discussions with the patient/parent. parent will accept or can afford. After the treatment plan is
presented, the parent should have the opportunity to ask
Comprehensive clinical examination7,8,16 questions regarding the proposed care and have concerns satis-
The clinical examination is tailored to the patient’s chief fied prior to giving informed consent. For adult patients with
complaint (e.g., initial visit to establish a dental home, acute special health care needs, it is important to determine who
traumatic injury, second opinion). A visual examination should legally can provide consent for treatment.21 The practitioner
precede other diagnostic procedures. Components of a com- should document interpreters or translation services used to
prehensive oral examination include: aid communication (e.g., in person, by telephone). Documen-
• general health/growth assessment/body mass index tation should include that the parent appeared to understand
calculation (e.g., height, weight, vital signs). and accepted the proposed procedures. Any special restrictions
• pain assessment. of the parent should be documented.
• extraoral soft tissue examination.

Progress notes Correspondence, consultations, and ancillary documents

An entry must be made in the patient’s record that accurately The primary care dentist often consults with other health
and objectively summarizes each visit. The entry must mini- care providers in the course of delivery of comprehensive oral
mally contain the following information: health care, especially for patients with special health care
• date of visit; needs or complex oral conditions. Communications with
• reason for visit/chief complaint; medical care providers or dental specialists should be incor-
• radiographic exposures and interpretation, if any; porated into the dental record. Written referrals to other care
• treatment rendered including, but not limited to, the providers should include the specific nature of the referral, as
type and dosage of anesthetic agents22, medications, well as pertinent patient history and clinical findings. Reports
and/or nitrous oxide/oxygen23, type/duration of pro- received from other health care providers should be incor-
tective stabilization24, treatment complications, and porated into the patient’s chart. A progress note should be
adverse outcomes; and made on correspondence sent or received regarding a referral,
• post-operative instructions and prescriptions as indicating documentation filed elsewhere in the patient’s
needed. chart. Copies of test results, prescriptions, laboratory work
orders, and other ancillary documents should be maintained
In addition, the entry generally should document: as part of the dental record.
• changes in the medical history, if any;
• adult accompanying child; Appendices*
• verification of compliance with preoperative * The information included in the following samples, devel-
instructions; oped by the AAPD, is provided as a tool for pediatric dentists
• reference to supplemental documents; and other dentists treating children. It was developed by
• patient behavior guidance; and experts in pediatric dentistry and is offered to facilitate excel-
• planned treatment for next visit. lence in practice. However, these samples do not establish a
standard of care. In issuing this information, the AAPD is
A standardized format may provide the practitioner a way not engaged in rendering legal or other professional advice.
to record the essential aspects of care on a consistent basis. If such services are required, competent legal or other profes-
One example of documentation is the SOAP note.25 SOAP is sional counsel should be sought.
an acronym for subjective (S) or the patient’s response and
feeling to treatment, objective (O) or the observations of the Appendix I—Medical history*
clinician, assessment (A) or diagnosis of the problem, and pro- Name and nickname
cedures accomplished and plans (P) for subsequent problem Date of birth
resolving activities. The signature or initials of the office staff Gender
member documenting the visit should be entered. Race/ethnicity
When sedation or general anesthesia is employed, addi-
Name, address, and telephone number of all physicians
tional documentation on a time-based record is required, as
Date of last physical examination
discussed in the AAPD’s Guideline for Monitoring and Man-
agement of Pediatric Patients Before, During and After Sedation Immunization status
for Diagnostic and Therapeutic Procedures: Update 2016.26 Summary of health problems
Progress notes also should include telephone conversations Any health conditions that necessitate antibiotics or other
regarding the patient’s care, appointment history (i.e., cancel- medications prior to dental treatment
lations, failures, tardiness), non-compliance with treatment Allergies/sensitivities/reactions
recommendations, and educational materials utilized (both Anesthetics, local and general
video and written), along with identification of the staff Sedative agents
member making the entry in the dental record. Drugs or medications
Environmental (including latex, food, dyes, metal,
Orthodontic treatment
acrylic)
The AAPD’s Management of the Developing Dentition and
Medications (including over-the-counter medications,
Occlusion in Pediatric Dentistry27 provides general recommen-
dations on the documentation of orthodontic care. Signs and/ vitamins, and homeopathic and herbal supplements)
or symptoms of TMJ disorders should be recorded when they —dose, frequency, reactions
occur before, during, or after orthodontic treatment.28 During Hospitalizations—reason, date, and outcome
orthodontic treatment, progress notes should include deficien- Surgeries—reason, date, and outcome
cies in oral hygiene, loose bands and brackets, patient com- Significant injuries—description, date, and outcome
plaints, caries, root resorption, and cancellations and failures.
Appendix continued on the next page.

General Genitourinary
Complications during pregnancy and/or birth Bladder infections
Prematurity Kidney infections
Congenital anomalies Pregnancy
Cleft lip/palate Systemic birth control
Inherited disorders Sexually transmitted infections
Nutritional deficiencies Musculoskeletal
Problems of growth or stature Arthritis
Head, ears, eyes, nose, throat Scoliosis
Lesions in/around mouth Bone/joint problems
Chronic adenoid/tonsil infections Temporomandibular disorders (TMD)—joint pop-
Chronic ear infections ping, clicking, locking, difficulties opening
Ear problems or chewing
Hearing impairments Integumentary
Eye problems Herpetic/ulcerative lesions
Visual impairments Eczema
Sinusitis Rash/hives
Speech impairments Dermatologic conditions
Apnea/snoring Neurologic
Mouth breathing Fainting
Cardiovascular Dizziness
Congenital heart defect/disease Autism spectrum disorder
Heart murmur Developmental disorders
Infective endocarditis Learning problems/delays (e.g., enrollment in special-
High blood pressure ized school or individualized education plan)
Rheumatic fever Mental disability
Rheumatic heart disease Brain injury
Respiratory Cerebral palsy
Asthma—medications, triggers, last attack, Convulsions/seizures
hospitalizations Epilepsy
Tuberculosis Headaches/migraines
Cystic fibrosis Hydrocephaly
Frequent colds/coughs Shunts—ventriculoperitoneal, ventriculoatrial,
Respiratory syncytial virus ventriculovenous
Reactive airway disease/breathing problems Psychiatric
Smoking Maltreatment (e.g., physical abuse, sexual abuse,
Gastrointestinal dental neglect, bullying)
Eating disorder (e.g., anorexia, bulimia, pica) Alcohol and chemical dependency
Ulcer Emotional disturbance
Excessive gagging Hyperactivity/attention deficit hyperactivity
Gastroesophageal/acid reflux disease disorder
Hepatitis Pediatric acute-onset neuropsychiatric syndrome
Jaundice (PANS)
Liver disease Obsessive compulsive disorder
Intestinal problems Psychiatric problems/treatment
Prolonged diarrhea Endocrine
Unintentional weight loss Diabetes
Lactose intolerance Growth delays
Dietary restrictions Hormonal problems
Precocious puberty
Thyroid problems

Hematologic/lymphatic/immunologic Appendix II—Dental History*

Anemia Previous dentist, address, telephone number
Blood disorder Date of last dental examination
Transfusion Date of last dental radiographs, number and type taken,
Excessive bleeding if known
Bruising easily Date of last fluoride treatment
Hemophilia Prenatal/natal history
Sickle cell disease/trait Family history of caries, including parents and siblings
Cancer, tumor, other malignancy History of smoking in the home
Immune disorder Medications or disorders that would impair salivary flow
Chemotherapy Injuries to teeth and jaws, including TMJ trauma
Radiation therapy When/where/how
Hematopoietic cell (bone marrow) transplant Treatment required
Infectious Dental pain and infections
Measles Habits (past and present) such as finger, thumb, pacifier,
Mumps tongue or lip sucking, bruxism, clenching
Rubella Snoring
Scarlet fever Diet and dietary habits
Varicella (chicken pox) Breast-feeding—frequency, weaned/when
Mononucleosis Bottle feeding/no-spill training (sippy) cup use
Cytomegalovirus (CMV) Frequency
Pertussis (whooping cough) Content—Formula, milk water, juice
Human immunodeficiency virus/acquired immune Weaned/when
deficiency syndrome (HIV/AIDS) Sugar-sweetened or sugar-containing beverages (e.g.,
Sexually transmitted infections sodas, fruit juice, sports drinks)—amount,
Lyme disease frequency
Zika virus Snacks—type, frequency
Family history Meals—balanced, frequency, restricted or special diet
Genetic disorders Oral hygiene
Problems with general anesthesia Frequency of brushing, flossing, oral rinse use
Serious medical conditions or illnesses Assisted/supervised
Social concerns Fluoride exposure
Chronic passive smoke exposure Primary source of drinking water—home,
Religious or philosophical objections to treatment daycare, other
Legal custody/guardianship status Water—tap, bottled, well, filtered/reverse osmosis
Systemic supplementation—tablets, drops
Topical—toothpaste, rinses, prescription
Previous orthodontic treatment
Behavior of child during past dental treatment
Behavior anticipated for future treatment

Appendix III—Clinical Examination* Intraoral hard tissue examination

General health/growth assessment Teeth present
Growth appropriate for age Supernumerary/missing teeth
Height/weight/frame size/body mass index (BMI) Dental development status
Vital signs—pulse, blood pressure Over-retained primary teeth
Extraoral examination Ankylosed teeth
Facial features Ectopic eruption
Nasal breathing Anomalies/pathologies noted
Lip posture Tooth size, shape discrepancies
Symmetry Tooth discoloration
Pathologies Enamel hypoplasia/fluorosis
Skin health Congenital defects
TMJ/TMD16 Existing restorations
Signs of clenching/bruxism Defective restorations
Headaches from TMD Caries
Pain Pulpal pathology 31,32
Joint sounds Traumatic injuries
Limitations or disturbance of movement or Third molars
function Radiographic examination33
Intra-oral soft tissue examination Developmental anomalies
Tongue Eruptive patterns/tooth positions/root resorption
Roof of mouth Crestal alveolar bone level
Frenulae Pulpal/furcation/periapical pathology
Floor of mouth Caries—presence, proximity to pulp space,
Tonsils/pharynx demineralization/remineralization
Lips Existing pulpal therapy/restorations
Pathologies noted Traumatic injury
Oral hygiene and periodontal assessment29,30 Calculus deposits
Oral hygiene, including an index or score Occult disease
Gingival health, including an index or score Explanation of inability to obtain diagnostic image
Probing of pocket depth, when indicated when indicated
Marginal discrepancies Caries-risk assessment
Calculus
Bone level discrepancies that are pathologic
Recession/inadequate attached gingiva References
Mobility 1. Speidel TM, Jerrold LJ. Record keeping to avoid or
defend lawsuits: A defense attorney’s perspective. Am J
Bleeding/suppuration
Orthod Dentofac Orthop 2004;125(6):754-6.
Furcation involvement
2. Heid DW, Chasteen J, Forrey AW. The electronic oral
Assessment of the developing occlusion health record. J Contemp Dent Pract 2002;3(1):43-5.
Facial profile 3. Atkinson JC, Zeller GG, Shah C. Electronic patient
Canine relationships records for dental school clinics: More than paperless
Molar relationships systems. J Dent Educ 2002;66(5):634-42.
Overjet 4. Balgrosky JA. Alignment: Health information systems
Overbite and technology and current challenges in healthcare. In:
Midline Essentials of Health Information Systems and Technol-
Crossbite ogy. Burlington, Mass.: Jones and Bartlett Learning; 2015:
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Spacing/crowding 5. Sfikas PM. HIPAA security regulations: Protecting
patients’ electronic health information. J Am Dent Assoc
Centric relation/centric occlusion discrepancy
2003;134(5):640-3.
Influence of oral habits
Appliances present

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hhs.gov/hipaa/for-professionals/index.html”. Accessed 21. American Academy of Pediatric Dentistry. Informed
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November 8, 2016. (Archived by WebCite at: “http:// consent. Pediatr Dent 2017;39(6):397-9.
www.webcitation.org/6lsBs7A0v”) 22. American Academy of Pediatric Dentistry. Use of local
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BEST PRACTICES: INFORMED CONSENT
Informed Consent
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Informed
2019 consent. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
Purpose Association (ADA) states that dentists are “required to provide

The American Academy of Pediatric Dentistry (AAPD) information to patients/parents about the dental health prob-
recognizes that informed consent is essential in the delivery of lems the dentist observes, the nature of any proposed treatment,
health care. The informed consent process allows the patient the potential benefits and risks associated with that treatment,
or, in the case of minors, the parent * to participate in and any alternatives to the treatment proposed, and the potential
retain autonomy over the health care received. Informed con- risks and benefits of alternative treatments, including no
sent also may decrease the practitioner’s liability from claims treatment.”7 Following the informed consent discussion, an
associated with miscommunication. Informed consent is assessment of patient/parental understanding should be made,
governed by the statutes and case laws of individual states; and any confusion about the treatment should be clarified by
oral health care providers should review the applicable laws the provider before consent is granted.5,8
and regulations of their state. Autonomy over healthcare decisions is a patient’s right. A
1914 New York state court ruled that “every human being of
Methods adult years and sound mind has a right to determine what
Recommendations on informed consent were originally shall be done with his own body….”9 Additionally, ruling from
developed by the Council on Clinical Affairs and adopted in the Supreme Court of North Dakota found that laws per-
2005.1 This document is a revision of the previous version, last taining to a physician’s duty to obtain informed consent also
revised in 2015.2 This revision included a literature search of pertained to dentists. 10 As court rulings and laws differ in
®
the PubMed /MEDLINE database using the terms: informed
consent, pediatric consent, pediatric informed consent, con-
each state, it is difficult to develop an inclusive recommendation.
The law generally has several criteria for selecting information
sent, informed refusal, cultural background informed consent, to provide to a patient/parent as part of an informed consent.
linguistic background informed consent, and interpreters Some states follow a patient-oriented standard—that informa-
informed consent; fields: all; limits: within the last 10 years, tion which a reasonably prudent patient/parent in same or
humans, English, review of legal cases. One hundred forty-two similar circumstances would wish to know.11-13 Other states
articles matched these criteria. Papers for review were chosen follow a practitioner-oriented standard—that information
from this list and from references within selected articles. which a health care provider, practicing within the standard
When data did not appear sufficient or were inconclusive, of care, would reasonably provide to a patient/parent in the
recommendations were based upon expert and/or consensus same circumstances.12-14 A hybrid approach, combining the
opinion by experienced researchers and legal practitioners. patient-oriented and practitioner-oriented standards, is fol-
lowed by some states.13,14 Finally, a subjective person standard
Background requires the practitioner to give information that the particular
Informed consent is the process by which a health care provider patient in question would want to know.5,11
gives relevant information concerning diagnosis and treatment Regardless of the standard a state has chosen to follow,
needs to a patient so that the patient can make a voluntary, the treating practitioner must disclose information that he
educated decision to accept or refuse treatment. Minor children considers material to the patient’s/parent’s decision-making
are legally unable to give informed consent, and intellectually process and provide a warning of death or serious bodily injury
disabled adults lack capacity to give consent. Parents are where that is a known risk of the procedure.13,15 The informed
authorized to grant or decline permission for treatment, with
assent or agreement from the child or incompetent adult
whenever possible. 3-6 All requirements of informed consent
ABBREVIATIONS
apply when the parent is acting on behalf of the child.3,4
AAPD: American Academy Pediatric Dentistry. ADA: American
Informed consent involves both ethical and legal obligations Dental Association.
of the health care provider to the patient. The American Dental
* In all AAPD oral health care policies and clinical recommendations, the term “parent” has a broad meaning encompassing a natural/biological or adoptive father or mother
of a child with full parental legal rights, a person recognized by state statute to have full parental legal rights, a parent who in the case of divorce has been awarded legal
custody of a child, a person appointed by a court to be the legal guardian of a minor child, or a foster parent (a noncustodial parent caring for a child without parental
support or protection who was placed by local welfare services or a court order). American Academy of Pediatric Dentistry. Introduction. Pediatr Dent 2018;40(6):5-7.

consent process generally excludes adverse consequences asso- to help parents in the decision-making process.20 Also, to
ciated with a simple procedure if the risk of occurrence is assure a person who is deaf or hearing impaired can consent,
considered remote and when such circumstances commonly a dentist carefully should consider the patient’s self-assessed
are understood by the profession to be so. communication needs before any treatment. Practitioners may
The ADA Code of Ethics recommends that dentists provide need to provide access to translation services (e.g., in person,
information “in a manner that allows the patient to become by telephone, by subscription to a language line) and sign lan-
involved in treatment decisions.”16 Pediatric dental health care guage services.3,20 Practitioners who receive federal funding, as
providers have the opportunity to guide and support the child well as those in a significant number of states, are mandated to
patient to become involved in his own health care. Young chil- provide these services at no cost to the patient.3,20 Supplements
dren lack the cognitive ability to participate in the informed such as informational booklets, videos, or models may be
consent discussion, but older children and adolescents who helpful to the patient in understanding a proposed procedure.
have gained experience as dental patients may be included. The oral discussion between provider and patient, not the com-
Information should be provided to the patient in an age- pletion of a form, is the important issue of informed consent.
appropriate manner, and practitioners should seek assent The consent form should document the oral discussion of
(agreement) from the patient whenever possible.17,18 Although the proposed therapy, including risks, benefits, and possible
the child can be involved, the parent is the individual giving alternative therapy, as well as no treatment.4,17,20
consent, and the parent is the individual who decides to accept Informed refusal occurs when the patient/parent refuses
or refuse treatment. The practitioner should be aware that the the proposed and alternative treatments. 7,19 The dentist must
adult accompanying the pediatric patient may not be a legal inform the patient/parent about the consequences of not
guardian allowed by law to consent to medical procedures. accepting the proposed. It is recommended by the ADA that
Examples of such an adult include a grandparent, stepparent, informed refusal be documented in the chart and that the
noncustodial parent in instances of divorce, babysitter, or practitioner should attempt to obtain an informed refusal
friend of the family. A child in foster care or a ward of the state signed by the parent for retention in the patient record. An
may be accompanied by a caretaker who may or may not be informed refusal, however, does not release the dentist from
allowed to consent to medical procedures, according to indi- the responsibility of providing a standard of care. 7 If the
vidual state law. It is advisable that the oral health care dentist believes the informed refusal violates proper standards
provider obtain a copy of court orders appointing a guardian of care, he/she should recommend the patient seek another
to verify who is authorized to consent for medical treatment opinion7 and/or dismiss the patient from the practice. If the
for the patient.18 One option to consider is obtaining a parent’s dentist suspects dental neglect, appropriate authorities should
authorization via a consent by proxy or power of attorney be informed.21
agreement for any other individual to make dental treatment When a consent form is utilized, it is best to use simple
decisions for a child.13,18 In situations where individuals other words and phrases. A modified or customized form is pre-
than the parent regularly bring the child to the dental office, ferred over a standard form and should be written so that it is
this can help eliminate doubt as to whether such individual readily understandable to a lay person.4,7,19,20 Overly broad state-
has the legal authority to provide informed consent. Practi- ments such as “any and all treatment deemed necessary…”
tioners, however, should consult their own attorney in deciding or “all treatment which the doctor in his/her best medical
whether to utilize such a form in their own practice. Another judgment deems necessary, including but not limited to…”
option for obtaining authorization for treatment is a telephone should be avoided. Courts have determined it to be so broad
conversation with the parent.18,19 The parent should be told and unspecific that it does not satisfy the duty of informed
there are two people on the telephone and asked to verify consent. Informed consent discussion, when possible, should
the patient’s name, date of birth, and address and to confirm occur on a day separate from the treatment and the practi-
he/she has responsibility for the patient.19 The parent is pre- tioner should avoid downplaying the risks involved with the
sented with all elements of a valid informed consent followed proposed therapy. 8 Items that should appear on a consent
by documentation in the patient’s chart with signatures.18,19 form are listed under Recommendations.
Written consent is required by most states before treatment Informed consent and informed refusal forms22 should be
of a patient. 13 Even if not mandated by state law, written procedure specific, with multiple forms likely to be used.
consent is advisable as it may decrease the liability from For example, risks associated with restorative procedures will
miscommunication.19 A patient’s or parent’s signing a consent differ from those associated with an extraction. Separate forms,
form should not preclude a thorough discussion. Studies have or separate areas outlining each procedure on the same form,
shown that even when seemingly adequate information has would be necessary to accurately advise the patient regarding
been presented to patients/parents, their ability to fully under- each procedure.7 Consent for sedation, general anesthesia, or
stand the information may be limited.8,11 Dentists should be behavior guidance techniques such as protective stabilization
aware of the cultural and linguistic backgrounds of their (i.e., immobilization) should be obtained separately from con-
patients and families and take care to ensure that information sent for other procedures.6,23 Consent may need to be updated
is available in culturally and linguistically competent formats or changed accordingly as changes in treatment plans occur.

When a primary tooth originally planned for pulp therapy 3. American Academy of Pediatrics Committee on Bioethics.
is determined to be non-restorable at the time of treatment, Informed consent in decision-making in pediatric practice
consent will need to be updated to reflect the change in treat- Pediatrics 2016;138(2):e20161484.
ment. Depending on state laws, this update may be in oral 4. American Medical Association. AMA code of medical
or written form. Dentists should consult their own attorney ethics opinions on consent, communication and decision
and state dental association as informed consent laws vary making. Available at: “https://www.ama-assn.org/sites/
by state.7 default/files/media-browser/code-of-medical-ethics-
chapter-2.pdf ”. Accessed March 24, 2019. (Archived by
Recommendations
Informed consent is the process of providing the patient with
®
WebCite at: “http://www.webcitation.org/739GB3Rlj”)
5. De Bord J. Informed Consent. Available at: “https://
relevant information regarding diagnosis and treatment needs depts.washington.edu/bioethx/topics/consent.html#ref1”.
so that an educated decision regarding treatment can be made
by the patient. In the case of a minor or intellectually disabled
“http://www.webcitation.org/72elabafp”)
®
adult, the parent gives informed permission with assent or 6. American Academy of Pediatric Dentistry. Protective
agreement from the patient whenever possible. The oral discus- stabilization for pediatric dental patients. Pediatr Dent
sion between provider and patient or parent, not the comple- 2018;40(special issue):268-73.
tion of a form, is the important issue of informed consent. A 7. American Dental Association Division of Legal Affairs.
written consent form serves as documentation of the consent Dental Records. Chicago, Ill.: American Dental Asso-
process and is required by most states. Other states allow the ciation; 2010:16.
oral discussion to be documented in the patient record. Dentists 8. Reid K. Informed consent in dentistry. J Law Med Ethics
should be aware of the cultural and linguistic backgrounds of 2017;45(1):77-94.
their patients and families and take care to ensure that infor- 9. Schloendorffer v Society of New York Hospital (105 N.E.
mation is available in culturally- and linguistically-competent 92); 1914.
formats to help patients and parents in the decision-making 10. Koapke v Herfendal, 660 NW 2d 206 (ND 2003).
process. 11. Kinnersley P, Phillips K, Savage K, et al. Interventions
Statutes and case law of individual states govern informed to promote informed consent for patients undergoing
consent. Oral health practitioners should review applicable surgical and other invasive healthcare procedures
state laws to determine their level of compliance. Consent (Review). Cochrane Database Syst Rev 2013;(7):
forms should be procedure specific, utilize simple terms, and CD009445.
avoid overly broad statements. When a practitioner utilizes 12. Informed consent to medical and surgical treatment. In:
an informed consent form, the following should be included: Legal Medicine, 7th ed. Philadelphia, Pa.: Moby; 2007;
1. legal name and date of birth of pediatric patient. 337-43.
2. legal name and relationship to the pediatric patient/ 13. LeBlang TR, Rosoff AJ, White C. Informed consent to
legal basis on which the person is granting permission medical and surgical treatment. In: Legal Medicine. 6th
on behalf of the patient. ed. Philadelphia, Pa.: Mosby; 2004.
3. patient’s diagnosis. 14. Nathanson v Kline, 350 P2d 1093 (Kan 1960).
4. nature and purpose of the proposed treatment in 15. Harris DM. Contemporary Issues in Healthcare Law
simple terms. and Ethics. 4th ed. Chicago, Ill.: Health Administration
5. potential benefits and risks associated with that Press; 2014:241-5.
treatment. 16. American Dental Association. Principles of Ethics &
6. professionally-recognized or evidence-based alternative Code of Professional Conduct. With official advisory
treatment – including no treatment – to recommended opinions revised to November 2018. Available at: “https:
therapy and risk(s). //www.ada.org/~/media/ADA/Member%20Center/
7. place for parent to indicate that all questions have Ethics/Code_Of_Ethics_Book_With_Advisory_Opinions
been asked and adequately answered. _Revised_to_November_2018.pdf?la=en”. Accessed
8. places for signatures of the parent, dentist, and an October 11, 2019.
office staff member as a witness. 17. Adewumi A, Hector MP, King JM. Children and in-
formed consent: A study of children’s perceptions and
References involvement in consent to dental treatment. Br Dent J
1. American Academy of Pediatric Dentistry. Informed 2001;191(5):256-9.
consent. Pediatr Dent 2005;27(suppl):182-3. 18. American Academy of Pediatrics Committee on Medical
2. American Academy of Pediatric Dentistry. Informed Liability. Consent by proxy for non urgent pediatric
Consent. Pediatr Dent 2015;37(special issue):315-7. care. Pediatrics 2017;139(2):e20163911.

19. Watterson DG. Informed consent and informed refusal 21. American Academy of Pediatric Dentistry, American
in dentistry. Registered Dental Hygienist. September Academy of Pediatrics. Oral and dental aspects of child
2012. Available at: “http://www.rdhmag.com/articles/ abuse and neglect. Pediatr Dent 2018;40(6):243-9.
print/volume-32/issue-9/features/informed-consent-and- 22. Professional Protector Plan for Dentists. Dental risk
informed-refusal.html”. Accessed March 24, 2019. management sample letters and consent forms. Available
20. Joint Commission. Informed consent: More than getting at: “http://www.protectorplan.com/forms”. Accessed
a signature. Available at: “https://www.jointcommission. March 24, 2019”.
org/assets/1/23/Quick_Safety_Issue_Twenty-One_ 23. American Academy of Pediatric Dentistry. Behavior
February_2016.pdf ”. Accessed March 24, 2019. (Archived guidance for the pediatric dental patient. Pediatr Dent
TshUp”)
®
by WebCite at: “http://www.webcitation.org/72U6 2018;40(special issue):254-67.

REFERENCE MANUAL V 40 / NO 6 18 / 19
474 ENDORSEMENTS
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
Endorsements
IADT Guidelines for the Management of
Traumatic Dental Injuries
Policy on the Management of Patients with Cleft
Lip/Palate & Other Craniofacial Anomalies
Periodontal Diseases of Children & Adolescents
Guideline for Periodontal Therapy
Treatment of Plaque-induced Gingivitis,
Chronic Periodontitis, and Other Clinical
Conditions
Healthy Beverages Consumption in ECC
ENDORSEMENTS 475
ENDORSEMENTS: GENERAL INTRODUCTION
International Association of Dental Traumatology

Guidelines for the Management of Traumatic Dental
Injuries: General Introduction
Endorsed by the American Academy
How to Cite: Levin L, Day PF, Hicks L, et al. International Association
of Dental Traumatology guidelines for the management of trau-
matic dental injuries: General introduction. Dent Traumatol 2020;
2020 36:309-313. https://doi.org/10.1111/edt.12574.
Authors
Liran Levin1 • Peter F. Day2 • Lamar Hicks3 • Anne O’Connell4 • Ashraf F. Fouad5 • Cecilia Bourguignon6 • Paul V. Abbott 7
Abstract
Traumatic dental injuries (TDIs) occur most frequently in children and young adults. Older adults also suffer TDIs but at significantly lower
rates than individuals in the younger cohorts. Luxation injuries are the most common TDIs in the primary dentition, whereas crown fractures
are more commonly reported for the permanent teeth. Proper diagnosis, treatment planning and follow up are very important to assure a
favorable outcome. These updates of the International Association of Dental Traumatology’s (IADT) Guidelines include a comprehensive
review of the currentdental literature using EMBASE, MEDLINE, PUBMED, Scopus, and Cochrane Databases for Systematic Reviews searches
from 1996 to 2019 and a search of the journal Dental Traumatology from 2000 to 2019. The goal of these guidelines is to provide information
for the immediate or urgent care of TDIs. It is understood that some follow-up treatment may require secondary and tertiary interventions
involving dental and medical specialists with experience in dental trauma. As with previous guidelines, the current working group included
experienced investigators and clinicians from various dental specialties and general practice. The current revision represents the best evidence
based on the available literature and expert opinions. In cases where the published data were not conclusive, recommendations were based
on the consensus opinions of the working group. They were then reviewed and approved by the members of the IADT Board of Directors.
It is understood that guidelines are to be applied using careful evaluation of the specific clinical circumstances, the clinician’s judgment,
and the patient’s characteristics, including the probability of compliance, finances and a clear understanding of the immediate and long-
term outcomes of the various treatment options vs non-treatment. The IADT does not, and cannot, guarantee favorable outcomes from
adherence to the Guidelines. However, the IADT believes that their application can maximize the probability of favorable outcomes.
(Dental Traumatology 2020;36:309-313; doi: 10.1111/edt.12574) Received May 19, 2020 | Accepted May 19, 2020
KEYWORDS: AVULSION, LUXATION, PREVENTION, TOOTH FRACTURE, TRAUMA
1 | INTRODUCTION teeth. Proper diagnosis, treatment planning and follow up are important to
Traumatic dental injuries (TDIs) occur frequently in children and young assure a favorable outcome.
adults, comprising 5% of all injuries. Twenty-five percent of all school children These updates of the International Association of Dental Traumatology’s
experience dental trauma and 33% of adults have experienced trauma to (IADT) Guidelines include a review of the current dental literature using
the permanent dentition, with the majority of the injuries occurring before EMBASE, MEDLINE, PUBMED, and Scopus searches from 1996 to 2019 and a
age 19. Luxation injuries are the most common TDIs in the primary dentition, search of the journal Dental Traumatology from 2000 to 2019.
whereas crown fractures are more commonly reported for the permanent The goal of these guidelines is to provide information for the immediate
and urgent care of TDIs. It is understood that some of the subsequent treat-
ment may require secondary and tertiary interventions involving specialists
1
Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada. 2School of
with experience in dental trauma.
Dentistry at the University of Leeds, Community Dental Service, Bradford District Care NHS The IADT published its first set of guidelines in 2001 and updated them
Trust, Leeds, UK. 3Division of Endodontics, University of Maryland School of Dentistry, UMB, in 2007. A further update was published in Dental Traumatology in 2012. As
Baltimore, MD, USA. 4Paediatric Dentistry, Dublin Dental University Hospital, Trinity College with previous guidelines, the current working group included experienced
Dublin, The University of Dublin, Dublin, Ireland 5Adams School of Dentistry, University of investigators and clinicians from various dental specialties and general prac-
North Carolina, Chapel Hill, NC, USA. 6Private Practice, Paris, France. 7UWA Dental School, tice. The current revision represents the best evidence based on the available
University of Western Australia, Perth, WA, Australia.
literature and expert professional judgment. In cases where the data were
Correspondence: Liran Levin, Chair of the IADT Guidelines Committee, Faculty of Medicine &
Dentistry, University of Alberta, 5-468 Edmonton Clinic Health Academy, 11405-87 Avenue NW,
not conclusive, recommendations were based on the consensus opinion of
5th Floor, Edmonton, AB T6G 1C9, Canada. the working group, then reviewed and approved by the members of the
Email: liran@ualberta.ca IADT Board of Directors.
Reprinted with permission of John Wiley and Sons.

© 2020 The Authors. Dental Traumatology 2020;36:309-313. Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1111/edt.12574”.
Dental Traumatology is published for the International Association of Dental Traumatology (IADT) by John Wiley and Sons Ltd.





It is understood that guidelines are to be applied with evaluation of the 2.2 | Immature vs mature permanent teeth
specific clinical circumstances, clinicians’ judgment and patients’ characteris- Every effort should be made to preserve the pulp in the immature perma-
tics, including but not limited to the probability of compliance, finances and nent tooth to ensure continued root development. A large majority of TDIs
an understanding of the immediate and long-term outcomes of treatment occur in children and teenagers where loss of a tooth has lifetime conse-
options vs non-treatment. The IADT does not, and cannot, guarantee favor- quences. The immature permanent tooth has considerable capacity for
able outcomes from adherence to the Guidelines, but the IADT believes that healing after traumatic pulp exposure, luxation injury, or root fracture.
their application can maximize the chances of a favorable outcome.
These Guidelines offer recommendations for the diagnosis and treat- 2.3 | Avulsion of permanent teeth
ment of specific TDIs. However, they provide neither the comprehensive nor The prognosis for avulsed permanent teeth is heavily dependent on the
the detailed information found in textbooks, the scientific literature, or the actions taken at the place of accident. Promotion of public awareness of
Dental Trauma Guide (DTG). The DTG can be accessed at http://www. first-aid treatment for the avulsed tooth is strongly encouraged. Treatment
dentaltraumaguide.org. In addition, the IADT website http://www.iadt- choices and prognosis for the avulsed tooth are largely dependent on the
dentaltrauma.org provides connection to the journal Dental Traumatology viability of the periodontal ligament (PDL), and the maturity of the root.
and other dental trauma information. See the IADT’s specific Guidelines for managing avulsed teeth.1
2 | GENERAL RECOMMENDATIONS 2. 4 | Patient/parent instructions

2 .1 | Special considerations for trauma to primary teeth Patient compliance with follow-up visits and home care contributes to better
A young child is often difficult to examine and treat due to lack of coopera- healing following a TDI. Both the patient and the parents of a young patient
tion and because of fear. This situation is distressing for both the child and should be advised regarding care of the injured tooth or teeth for optimal
the parents. It is important to keep in mind that there is a close relationship healing, preventing further injury, employing meticulous oral hygiene, and
between the root apex of the injured primary tooth and the underlying rinsing with an antibacterial agent such as alcohol-free chlorhexidine
permanent tooth germ. Tooth malformation, impacted teeth and eruption gluconate 0.12% for 1-2 weeks. Alternatively, with a young child, it is desirable
disturbances in the developing permanent dentition are some of the con- to apply the chlorhexidine to the affected area with a cotton swab.
sequences that can occur following severe injuries to primary teeth and/or
alveolar bone. A child’s maturity and ability to cope with the emergency 2.5 | Summary tables for follow up, splinting duration and core outcomes
situation, the time for shedding of the injured tooth, and the occlusion are To help summarise activities for the follow-up appointment and splinting
all important factors that influence treatment. Multiple traumatic episodes regimes, Tables 1-3 are presented for different injuries in the primary and
are also common in children and this may affect the outcomes following permanent dentitions. The core outcome variables, explained in the next
trauma to a tooth. paragraph, are also included.
2.6 | Core outcome set

When the worldwide trauma literature is reviewed, it is dominated by one
center in Copenhagen. The lifetime work of Dr Andreasen and his research
group is remarkable in both its longevity and the prolific publication of
their results. One of the key fundamentals of scientific research is replication,
where the results found in one center with one group of patients are also
consistently seen across other patient groups. It is essential that the results
from other centers are published even when they confirm the findings from
earlier studies. By increasing the number of studies available for clinicians
and researchers to analyze, the ability to compare, contrast and combine
studies as appropriate is enhanced.
The IADT recently developed a core outcome set (COS) for traumatic
dental injuries (TDI) in children and adults.2 This is one of the first COS
developed in dentistry and follows a robust consensus methodology and is
underpinned by a systematic review of the outcomes used in the trauma
literature.3 A number of outcomes were identified as recurring throughout
the different injury types. These outcomes were then included as “generic”—
that is relevant to all TDI. Injury-specific outcomes were also determined as
those outcomes related only to one or more particular TDI. Additionally, the
study established what, how, when and by whom these outcomes should be
measured. Tables 1 and 2 show the generic and injury-specific outcomes to
be recorded at the follow-up review appointments for the different traumatic
injuries. Further information for each outcome is described in the original
paper.2
CONFLICT OF INTEREST
The authors confirm that they have no conflict of interest.
ETHICAL APPROVAL
No ethic approval was required for this paper.


ORCID REFERENCES
Liran Levin https://orcid.org/0000-0002-8123-7936 1. Fouad AF, Abbott PV, Tsilingaridis G, et al. International Association of
Peter F. Day https://orcid.org/0000-0001-9711-9638 Dental Traumatology guidelines for the management of traumatic
dental injuries: 2. Avulsion of permanent teeth [ published online
Anne O’Connell https://orcid.org/0000-0002-1495-3983
ahead of print, 2020 May 27]. Dent Traumatol. 2020. https://doi.org/
Ashraf F. Fouad https://orcid.org/0000-0001-6368-1665 10.1111/edt.12573
Paul V. Abbott https://orcid.org/0000-0001-5727-4211 2. Kenny KP, Day PF, Sharif MO, Parashos P, Lauridsen E, Feldens CA, et
al. What are the important outcomes in traumatic dental injuries? An
international approach to the development of a core outcome set.
Dent Traumatol. 2018;34:4–11.
3. Sharif MO, Tejani-Sharif A, Kenny K, Day PF. A systematic review of
outcome measures used in clinical trials of treatment interventions
following traumatic dental injuries. Dent Traumatol. 2015;31:422–8.


ENDORSEMENTS: FRACTURES AND LUXATIONS

Injuries: 1. Fractures and Luxations
How to Cite: Bourguignon C, Cohenca N, Lauridsen E, et al.
International Association of Dental Traumatology guidelines for
the management of traumatic dental injuries: 1. Fractures and
2020 luxations. Dent Traumatol 2020;36:314-330. https://doi.org/10.1111/
edt.12578.
Authors
Cecilia Bourguignon1 • Nestor Cohenca2 • Eva Lauridsen3 • Marie Therese Flores4 • Anne C. O’Connell5 • Peter F. Day6 • Georgios Tsilingaridis7,8 • Paul V. Abbott9
Ashraf F. Fouad10 • Lamar Hicks11 • Jens Ove Andreasen12 • Zafer C. Cehreli13 • Stephen Harlamb14 • Bill Kahler15 • Adeleke Oginni16 • Marc Semper17 • Liran Levin18
Abstract
Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young adults. Crown fractures and luxations of these
teeth are the most commonly occurring of all dental injuries. Proper diagnosis, treatment planning, and follow up are important for achieving
a favorable outcome. Guidelines should assist dentists and patients in decision making and in providing the best care possible, both effec-
tively and efficiently. The International Association of Dental Traumatology (IADT) has developed these Guidelines as a consensus statement
after a comprehensive review of the dental literature and working group discussions. Experienced researchers and clinicians from various
specialties and the general dentistry community were included in the working group. In cases where the published data did not appear
conclusive, recommendations were based on the consensus opinions of the working group. They were then reviewed and approved by the
members of the IADT Board of Directors. These Guidelines represent the best current evidence based on literature search and expert
opinion. The primary goal of these Guidelines is to delineate an approach for the immediate or urgent care of TDIs. In this first article, the
IADT Guidelines cover the management of fractures and luxations of permanent teeth. The IADT does not, and cannot, guarantee favorable
outcomes from adherence to the Guidelines. However, the IADT believes that their application can maximize the probability of favorable
outcomes. (Dental Traumatology 2020;36:314-330; doi: 10.1111/edt.12578) Received May 19, 2020 | Accepted May 19, 2020.
1 | INTRODUCTION
The vast majority of traumatic dental injuries (TDI) occur in children and
teenagers where loss of a tooth has lifetime consequences. Treatments for
1
these younger age groups may be different than in adults, mainly due to
Specialist Private Practice, Paris, France. 2Department of Pediatric Dentistry, University of
Washington and Seattle Children’s Hospital, Seattle, WA, USA. 3Resource Center for Rare Oral
immature teeth and pubertal facial growth. The purpose of these Guidelines
Diseases, Copenhagen University Hospital, Copenhagen, Denmark. 4Department of Pediatric is to improve management of injured teeth and minimize complications
Dentistry, Faculty of Dentistry, Universidad de Valparaíso, Valparaíso, Chile. 5Paediatric Dentis- resulting from trauma.
try, Dublin Dental University Hospital, Trinity College Dublin, The University of Dublin, Dublin,
Ireland. 6School of Dentistry, University of Leeds and Community Dental Service Bradford Dis- 2 | CLINICAL EXAMINATION
trict Care NHS Trust, Leeds, UK. 7Division of Orthodontics and Pediatric Dentistry, Department Trauma involving the dento-alveolar region is a frequent occurrence which
of Dental Medicine, Karolinska Institutet, Huddinge, Sweden. 8Center for Pediatric Oral Health
can result in the fracture and displacement of teeth, crushing, and/or fracturing
Research, Stockholm, Sweden. 9UWA Dental School, University of Western Australia, Nedlands,
WA, Australia. 10Adams School of Dentistry, University of North Carolina, Chapel Hill, NC, USA.
of bone, and soft tissue injuries including contusions, abrasions, and lacera-
11
Division of Endodontics, University of Maryland School of Dentistry, UMB, Baltimore, MD, tions. Available current literature provides protocols, methods, and documen-
USA. 12Department of Oral and Maxillofacial Surgery, Resource Centre for Rare Oral Diseases, tation for the clinical assessment of traumatic dental injuries (TDI), trauma
University Hospital in Copenhagen (Rigshospitalet), Copenhagen, Denmark. 13Department of first aid, patient examination, factors that affect treatment planning decisions,
Pediatric Dentistry, Faculty of Dentistry, Hacettepe University, Ankara, Turkey. 14Faculty of and the importance of communicating treatment options and prognosis to
Medicine and Health, The University of Sydney, Sydney, NSW, Australia. 15School of Dentistry, traumatized patients.1–3
The University of Queensland, St Lucia, Qld, Australia. 16Faculty of Dentistry, College of Health
The combination of two different types of injuries occurring concurrently
Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria. 17Specialist Private Practice, Bremen,
Germany. 18Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
to the same tooth will be more detrimental than a single injury, creating a
Correspondence: Liran Levin, Chair of the IADT Guidelines Committee, Faculty of Medicine & negative synergistic effect. Concurrent crown fractures significantly increase
Dentistry, University of Alberta, 5-468 Edmonton Clinic Health Academy, 11405-87 Avenue NW, the risk of pulp necrosis and infection in teeth with concussion or sublux-
5th Floor, Edmonton, AB T6G 1C9, Canada. Email: liran@ualberta.ca ation injuries and mature root development.4 Similarly, crown fractures with


or without pulp exposure significantly increase the risk of pulp necrosis and
infection in teeth with lateral luxation.5,6
Kenny et al7 have developed a core outcome set (COS) for TDIs in children
and adults. Outcomes were identified as recurring throughout the different
injury types. These outcomes were then identified as “generic” or “Injury-
specific.” Generic outcomes are relevant to all TDIs while “Injury-specific
outcomes” are related to only one or more specific TDIs. Additionally, the
core outcome set also established what, how, when, and by whom these
outcomes should be measured (Tables 1-13).
3 | RADIOGRAPHIC EXAMINATION
Several conventional two-dimensional imaging projections and angulations
are recommended.2,8,9 The clinician should evaluate each case and determine
which radiographs are required for the specific case involved. A clear justifi-
cation for taking a radiograph is essential. There needs to be a strong likeli-
hood that a radiograph will provide the information that will positively
influence the selection of the treatment provided. Furthermore, initial
radiographs are important as they provide a baseline for future comparisons
at follow-up examinations. The use of film holders is highly recommended
to allow standardization and reproducible radiographs.
Since maxillary central incisors are the most frequently affected teeth,
the radiographs listed below are recommended to thoroughly examine the
injured area:
1. One parallel periapical radiograph aimed through the midline to show the
two maxillary central incisors.
2. One parallel periapical radiograph aimed at the maxillary right lateral
incisors (should also show the right canine and central incisor).
3. One parallel periapical radiograph aimed at the maxillary left lateral
incisor (should also show the left canine and central incisor).
4. One maxillary occlusal radiograph.
5. At least one parallel periapical radiograph of the lower incisors centered
on the two mandibular centrals. However, other radiographs may be
indicated if there are obvious injuries of the mandibular teeth (eg, similar
periapical radiographs as above for the maxillary teeth, mandibular occlusal
radiograph).
The radiographs aimed at the maxillary lateral incisors provide different

horizontal (mesial and distal) views of each incisor, as well as showing the
canine teeth. The occlusal radiograph provides a different vertical view of
the injured teeth and the surrounding tissues, which is particularly helpful
in the detection of lateral luxations, root fractures, and alveolar bone
fractures.2,8,9
The above radiographic series is provided as an example. If other teeth
are injured, then the series can be modified to focus on the relevant tooth/
teeth. Some minor injuries, such as enamel infractions, may not require all of
these radiographs.
Radiographs are necessary to make a thorough diagnosis of dental
injuries. Tooth root and bone fractures, for instance, may occur without any
clinical signs or symptoms and are frequently undetected when only one
radiographic view is used. Additionally, patients sometimes seek treatment
several weeks after the trauma occurred when clinical signs of a more
serious injury have subsided. Thus, dentists should use their clinical judgment
and weigh the advantages and disadvantages of taking several radiographs.
Cone beam computerized tomography (CBCT) provides enhanced visual-
ization of TDIs, particularly root fractures, crown/root fractures, and lateral
luxations. CBCT helps to determine the location, extent, and direction of a
fracture. In these specific injuries, 3D imaging can be useful and should be
considered, if available.9–11 A guiding principle when considering exposing
a patient to ionizing radiations (eg, either 2D or 3D radiographs) is whether
the image is likely to change the management of the injury.






















4 | PHOTOGRAPHIC DOCUMENTATION sports, meticulous oral hygiene, and rinsing with an antibacterial agent such
The use of clinical photographs is strongly recommended for the initial as chlorhexidine gluconate 0.12%.
documentation of the injury and for follow-up examinations. Photographic
documentation allows monitoring of soft tissue healing, assessment of tooth 9 | FOLLOW UPS AND DETECTION OF POST-TRAUMATIC COMPLICATIONS
discoloration, the re-eruption of an intruded tooth, and the development of Follow ups are mandatory after traumatic injuries. Each follow up should
infra-positioning of an ankylosed tooth. In addition, photographs provide include questioning of the patient about any signs or symptoms, plus clini-
medico-legal documentation that could be used in litigation cases. cal and radiographic examinations and pulp sensibility testing. Photographic
documentation is strongly recommended. The main post-traumatic compli-
5 | PULP STATUS EVALUATION: SENSIBILITY AND VITALITY TESTING cations are as follows: pulp necrosis and infection, pulp space obliteration,
5.1 | Sensibility tests several types of root resorption, breakdown of marginal gingiva and bone.
Sensibility testing refers to tests (cold test and electric pulp test) used to Early detection and management of complications improves prognosis.
determine the condition of the pulp. It is important to understand that
sensibility testing assesses neural activity and not vascular supply. Thus, this 1 0 | STAGE OF ROOT DEVELOPMENT—IMMATURE (OPEN APEX) VS
testing might be unreliable due to a transient lack of neural response or MATURE (CLOSED APEX) PERMANENT TEETH
undifferentiation of A-delta nerve fibers in young teeth.12–14 The temporary Every effort should be made to preserve the pulp, in both mature and im-
loss of sensibility is a frequent finding during post-traumatic pulp healing, mature teeth. In immature permanent teeth, this is of utmost importance
especially after luxation injuries.15 Thus, the lack of a response to pulp sensi- in order to allow continued root development and apex formation. The vast
bility testing is not conclusive for pulp necrosis in traumatized teeth.16–19 majority of TDIs occur in children and teenagers, where loss of a tooth has
Despite this limitation, pulp sensibility testing should be performed initially lifetime consequences. The pulp of an immature permanent tooth has con-
and at each follow-up appointment in order to determine if changes occur siderable capacity for healing after a traumatic pulp exposure, luxation injury,
over time. It is generally accepted that pulp sensibility testing should be or root fracture. Pulp exposures secondary to TDIs are amenable to con-
done as soon as practical to establish a baseline for future comparison servative pulp therapies, such as pulp capping, partial pulpotomy, shallow
testing and follow up. Initial testing is also a good predictor for the long-term or partial pulpotomy, and cervical pulpotomy, which aim to maintain the
prognosis of the pulp.12–15,20 pulp and allow for continued root development.28–31 In addition, emerging
therapies have demonstrated the ability to revascularize/revitalize teeth by
5.2 | Vitality tests attempting to create conditions allowing for tissue in-growth into the root
The use of pulse oximetry, which measures actual blood flow rather than the canals of immature permanent teeth with necrotic pulps.32–37
neural response, has been shown to be a reliable noninvasive and accurate
way of confirming the presence of a blood supply (vitality) in the pulp.14,21 1 1 | COMBINED INJURIES
The current use of pulse oximetry is limited due to the lack of sensors speci- Teeth frequently sustain a combination of several injuries. Studies have
fically designed to fit dental dimensions and the lack of power to penetrate demonstrated that crown-fractured teeth, with or without pulp exposure and
through hard dental tissues. with a concomitant luxation injury, experience a greater frequency of pulp
Laser and ultrasound Doppler flowmetry are promising technologies to necrosis and infection.38 Mature permanent teeth that sustain a severe TDI
monitor pulp vitality. after which pulp necrosis and infection is anticipated are amenable to
preventive endodontic treatment.
6 | STABILIZATION/SPLINTING: TYPE AND DURATION Since prognosis is worse in combined injuries, the more frequent follow-
Current evidence supports short-term, passive, and flexible splints for splint- up regimen for luxation injuries prevails over the less frequent regime for
ing of luxated, avulsed, and root-fractured teeth. In the case of alveolar bone fractures.
fractures, splinting of the teeth may be used for bone segment immobili-
zation. When using wire-composite splints, physiological stabilization can 12 | PULP CANAL OBLITERATION
be obtained with stainless steel wire up to 0.4 mm in diameter.22 Splinting Pulp canal obliteration (PCO) occurs more frequently in teeth with open
is considered best practice in order to maintain the repositioned tooth in apices which have suffered a severe luxation injury. It usually indicates the
its correct position and to favor initial healing while providing comfort and presence of viable tissue within the root canal. Extrusion, intrusion, and
controlled function.23–25 It is critically important to keep composite and lateral luxation injuries have high rates of PCO.39,40 Subluxated and crown-
bonding agents away from the gingiva and proximal areas to avoid plaque fractured teeth also may exhibit PCO, although with lower frequency.41
retention and secondary infection. This allows better healing of the marginal Additionally, PCO is a common occurrence following root fractures.42,43
gingiva and bone. Splinting time (duration) will depend on the injury type.
Please see the recommendations for each injury type (Tables 1-13). 1 3 | ENDODONTIC CONSIDER ATIONS FOR LUXATED AND FRACTURED
TEETH
7 | USE OF ANTIBIOTICS 13.1 | Fully developed teeth (mature teeth with closed apex)
There is limited evidence for the use of systemic antibiotics in the emergency The pulp may survive after the trauma, but early endodontic treatment is
management of luxation injuries and no evidence that antibiotics improve typically advisable for fully developed teeth that have been intruded, severe-
the outcomes for root-fractured teeth. Antibiotic use remains at the dis- ly extruded, or laterally luxated. Calcium hydroxide is recommended as an
cretion of the clinician as TDIs are often accompanied by soft tissue and intra-canal medicament to be placed 1-2 weeks after trauma for up to 1
other associated injuries, which may require other surgical intervention. In month followed by root canal filling.44 Alternately, a corticosteroid/antibiotic
addition, the patient’s medical status may warrant antibiotic coverage.26,27 paste can be used as an anti-inflammatory and anti-resorptive intra-canal
medicament to prevent external inflammatory (infection-related) resorption.
8 | PATIENT INSTRUCTIONS If such a paste is used, it should be placed immediately (or as soon as
Patient compliance with follow-up visits and home care contribute to better possible) following repositioning of the tooth and then left in situ for at least
healing following a TDI. Both patients and parents or guardians should be 6 weeks.45–48 Medicaments should be carefully applied within the root canal
advised regarding care of the injured tooth/teeth and tissues for optimal system while avoiding contact with the access cavity walls due to possible
healing, prevention of further injury by avoidance of participation in contact discoloration of the crown.48


13.2 | Incompletely developed teeth (immature teeth with open apex) ORCID
The pulp of fractured and luxated immature teeth may survive and heal, or Cecilia Bourguignon https://orcid.org/0000-0003-2753-649X
there may be spontaneous pulp revascularization following luxation. Thus, Nestor Cohenca https://orcid.org/0000-0002-0603-5437
root canal treatment should be avoided unless there is clinical or radiographic Eva Lauridsen https://orcid.org/0000-0003-0859-7262
evidence of pulp necrosis or periapical infection on follow-up examinations.
Marie Therese Flores https://orcid.org/0000-0003-2412-190X
The risk of infection-related (inflammatory) root resorption should be
weighed against thechances of obtaining pulp space revascularization. Such Anne C. O’Connell https://orcid.org/0000-0002-1495-3983
resorption is very rapid in children. Hence, regular follow ups are manda- Peter F. Day https://orcid.org/0000-0001-9711-9638
tory so root canal treatment can be commenced as soon as this type of re- Georgios Tsilingaridis https://orcid.org/0000-0001-5361-5840
sorption is detected (see below). Incompletely developed teeth that have Paul V. Abbott https://orcid.org/0000-0001-5727-4211
been intruded and also have a crown fracture (combined traumatic injuries)
Ashraf F. Fouad https://orcid.org/0000-0001-6368-1665
are at higher risk of pulp necrosis and infection and, therefore, immediate
or early root canal treatment might be considered in these cases. Other Bill Kahler https://orcid.org/0000-0002-4181-3871
endodontic treatment of teeth with incompletely developed roots may in- Liran Levin https://orcid.org/0000-0002-8123-7936
volve apexification or pulp space revascularization/revitalization techniques.
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resorption, root canal treatment should be initiated immediately. The canal and diagnosis of dental injuries. In: Andreasen JO, Andreasen FM,
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and follows a robust consensus methodology. Some outcomes were iden- al. What are the important outcomes in traumatic dental injuries? An
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Traumatol. 2020;36:309–13.


ENDORSEMENTS: AVULSION OF PERMANENT TEETH

Injuries: 2. Avulsion of Permanent Teeth
How to Cite: Fouad AF, Abbott PV, Tsilingaridis G, et al. International
Association of Dental Traumatology guidelines for the management
of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent
2020 Traumatol 2020;36:331-342. https://doi.org/10.1111/edt.12573.
Authors
Ashraf F. Fouad1 • Paul V. Abbott2 • Georgios Tsilingaridis3,4 • Nestor Cohenca5 • Eva Lauridsen6 • Cecilia Bourguignon7 • Anne C. O’Connell8 • Marie Therese Flores9
Peter F. Day10 • Lamar Hicks1 1 • Jens Ove Andreasen12 • Zafer C. Cehreli13 • Stephen Harlamb14 • Bill Kahler15 • Adeleke Oginni16 • Marc Semper17 • Liran Levin18
Abstract
Avulsion of permanent teeth is one of the most serious dental injuries. Prompt and correct emergency management is essential for attaining
the best outcome after this injury. The International Association of Dental Traumatology (IADT) has developed these Guidelines as a consensus
statement after a comprehensive review of the dental literature and working group discussions. It represents the current best evidence and
practice based on that literature search and expert opinions. Experienced researchers and clinicians from various specialties and the general
dentistry community were included in the working group. In cases where the published data did not appear conclusive, recommendations
were based on consensus opinions or majority decisions of the working group. They were then reviewed and approved by the members of
the IADT Board of Directors. The purpose of these Guidelines is to provide clinicians with the most widely accepted and scientifically plausi-
ble approaches for the immediate or urgent care of avulsed permanent teeth. The IADT does not, and cannot, guarantee favorable outcomes
from adherence to the Guidelines. However, the IADT believes that their application can maximize the probability of favorable outcomes.
(Dental Traumatology 2020;36:331-342; doi: 10.1111/edt.12573) Received May 19, 2020 | Accepted May 19 2020.
1 | INTRODUCTION
Avulsion of permanent teeth is seen in 0.5%–16% of all dental injuries.1,2
Numerous studies have shown that this injury is one of the most serious
dental injuries, and the prognosis is very much dependent on the actions
taken at the place of accident and promptly following the avulsion.3-17
1
Adams School of Dentistry, University of North Carolina, Chapel Hill, NC, USA. 2UWA Dental
Replantation is, in most situations, the treatment of choice but cannot
School, University of Western Australia, Crawley, WA, Australia. 3Division of Orthodontics and
Pediatric Dentistry, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden.
always be carried out immediately. Appropriate emergency management
4
Center for Pediatric Oral Health Research, Stockholm, Sweden. 5Department of Pediatric Den- and a treatment plan are important for a good prognosis. There are also
tistry, University of Washington and Seattle Children’s Hospital, Seattle, WA, Australia. 6Resource individual situations when replantation is not indicated (eg, severe caries or
Center for Rare Oral Diseases, Copenhagen University Hospital, Copenhagen, Denmark. 7Private periodontal disease, an uncooperative patient, severe cognitive impairment
Practice, Paris, France. 8Paediatric Dentistry, Dublin Dental University Hospital, Trinity College requiring sedation, severe medical conditions such as immunosuppression,
Dublin, The University of Dublin, Dublin, Ireland. 9Department of Pediatric Dentistry, Faculty of and severe cardiac conditions) which must be dealt with individually. Al-
Dentistry, Universidad de Valparaíso, Valparaíso, Chile. 10School of Dentistry, Community Dental
though replantation may save the tooth, it is important to realize that some
Service Bradford District Care NHS Trust, University of Leeds, Leeds, UK. 1 1 Division of Endodontics,
University of Maryland School of Dentistry, UMB, Baltimore, MD, USA. 12Department of Oral and
of the replanted teeth have low probability of long-term survival and may
Maxillofacial Surgery, Resource Centre for Rare Oral Diseases, University Hospital in Copenhagen be lost or condemned to extraction at a later stage. However, not replanting
(Rigshospitalet), Copenhagen, Denmark. 13Department of Pediatric Dentistry, Faculty of Dentistry, a tooth is an irreversible decision and therefore saving it should be attempted.
Hacettepe University, Ankara, Turkey. 14Faculty of Medicine and Health, The University of Sydney, In this regard, a recent study has shown that replanted teeth have higher
Sydney, NSW, Australia. 15School of Dentistry, The University of Queensland, St Lucia, QLD, Austra- chances of long-term survival after following the IADT treatment guidelines,
lia. 16Faculty of Dentistry, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria compared to previous studies.18
17
Specialist Private Practice, Bremen, Germany. 18Faculty of Medicine and Dentistry, University of
Guidelines for the emergency management of dental traumatic injuries
Alberta, Edmonton, AB, Canada.
are useful for delivering the best possible care in an efficient manner. The
Dentistry, University of Alberta, 5-468 Edmonton Clinic Health Academy, 11405-87 Avenue NW, International Association of Dental Traumatology (IADT) has developed a
5th Floor, Edmonton, AB T6G 1C9, Canada. consensus statement after an update of the dental literature and discussions
Email: liran@ualberta.ca among expert groups. Experienced international researchers and clinicians


from various specialties and general dentistry were included in the groups. suitable and convenient storage mediums. Although water is a poor
In cases where the data did not appear conclusive, recommendations were medium, it is better than leaving the tooth to air-dry.28,29
based on best available evidence, consensus opinion, and in some situa- 7. The tooth can then be brought with the patient to the emergency clinic.
tions majority decisions among IADT Board members. The guidelines should 8. See a dentist or dental professional immediately.
therefore be seen as the current best evidence and practice based on litera-
ture research and professional opinion. The poster “Save a Tooth” is available in multiple languages: Arabic,
Guidelines should assist dentists, other healthcare professionals, and Basque, Bosnian, Bulgarian, Catalan, Czech, Chinese, Dutch, English, Estonian,
patients in decision-making. Also, they should be clear, readily understand- French, Georgian, German, Greek, Hausa, Hebrew, Hindi (India), Hungarian,
able, and practical with the aim of delivering appropriate care as effectively Icelandic, Indonesian Bahasa, Italian, Kannada (India), Korean, Latvian,
and efficiently as possible. Guidelines are to be applied with the clinician’s Marathi (India), Persian, Polish, Portuguese, Russian, Sinhalese, Slovenian,
judgment of the specific clinical circumstances and patient characteristics, Spanish, Tamil (India), Thai, Turkish, Ukrainian, and Vietnamese. This educa-
including but not limited to compliance, finances, and understanding of tional resource can be obtained at the IADT website: http://www.iadt-dental
the immediate and longterm outcomes of treatment alternatives vs non- trauma.org
treatment. The IADT cannot and does not guarantee favorable outcomes The IADT’s free app, “ToothSOS” for mobile phones, is another useful
from strict adherence to the Guidelines, but believes that their application source of information for patients, providing instructions on what to do in
can maximize the chances of a favorable outcome. Guidelines undergo an emergency situation after a dental injury, including avulsion of a perma-
periodic updates. The following guidelines by the International Association of nent tooth.
Dental Traumatology (IADT) represent a revision and update of the previous
guidelines that were published in 2012.19-21 3 | TREATMENT GUIDELINES FOR AVULSED PERMANENT TEETH
In these IADT Guidelines for management of avulsed permanent teeth, The choice of treatment is related to the maturity of the root (open or
the literature has been searched using Medline and Scopus databases utiliz- closed apex) and the condition of the periodontal ligament (PDL) cells. The
ing the search words: avulsion, exarticulation and replantation. The task group condition of the PDL cells is dependent on the time out of the mouth and
discussed treatment in detail and reached consensus as to what to recom- on the storage medium in which the avulsed tooth was kept. Minimizing
mend as the current best practice for emergency management. This text the dry time is critical for survival of the PDL cells. After an extra-alveolar
aims to provide concise and necessary advice for treatment in the emergency dry time of 30 minutes, most PDL cells are non-viable.30,31 For this reason,
situation. information regarding the dry time of the tooth prior to replantation or prior
The final decision regarding patient care remains primarily with the to being placed in a storage medium is very important to obtain as part
treating dentist. However, the consent to implement the final decision rests of the history. From a clinical point of view, it is important for the clinician
with the patient, parent, or guardian. For ethical reasons, it is important that to assess the condition of the PDL cells by classifying the avulsed tooth
the dentist provides the patient and guardian with pertinent information into one of the following three groups before commencing treatment:
relating to treatment to ensure they are maximally involved in the decision- 1. The PDL cells are most likely viable. The tooth has been replanted im-
making process. mediately or within a very short time (about 15 minutes) at the place
of accident.
2 | FIRST AID FOR AVULSED TEETH AT THE PLACE OF ACCIDENT 2. The PDL cells may be viable but compromised. The tooth has been kept
Dentists should be prepared to give appropriate advice to the public about in a storage medium (eg, milk, HBSS (Save-a-Tooth or similar product),
first aid for avulsed teeth.2,11,22-27 An avulsed permanent tooth is one of the saliva, or saline, and the total extra-oral dry time has been <60 minutes).
few real emergency situations in dentistry. In addition to increasing the 3. The PDL cells are likely to be non-viable. The total extra-oral dry time
public awareness by mass media campaigns or other means of communi- has been more than 60 minutes, regardless of the tooth having been
cation, parents, guardians and teachers should receive information on how stored in a medium or not.
to proceed following these severe and unexpected injuries. Also, instructions
may be given by telephone to people at the emergency site. Immediate These three groups provide guidance to the dentist on the prognosis of
replantation of the avulsed tooth is the best treatment at the place of the the tooth. Although exceptions to the prognosis do occur, the treatment
accident. If for some reason this cannot be carried out, there are alternatives will not change, but may guide the dentist’s treatment decisions.
such as using different types of storage media.
If a tooth is avulsed, make sure it is a permanent tooth (primary teeth 3.1 | Treatment guidelines for avulsed permanent teeth with a closed
should not be replanted) and follow these recommended instructions: apex
1. Keep the patient calm. 3.1.1 | T he tooth has been replanted at the site of injury or before the
2. Find the tooth and pick it up by the crown (the white part). Avoid patient’s arrival at the dental clinic
touching the root. Attempt to place it back immediately into the jaw. 1. Clean the injured area with water, saline, or chlorhexidine.
3. If the tooth is dirty, rinse it gently in milk, saline or in the patient’s saliva 2. Verify the correct position of the replanted tooth both clinically and
and replant or return it to its original position in the jaw.28,29 radiographically.
4. It is important to encourage the patient/guardian/teacher/other person 3. Leave the tooth/teeth in place (except where the tooth is malpositioned;
to replant the tooth immediately at the emergency site. the malpositioning needs to be corrected using slight digital pressure)
5. Once the tooth has been returned to its original position in the jaw, the 4. Administer local anesthesia, if necessary, and preferably with no vaso-
patient should bite on gauze, a handkerchief or a napkin to hold it in constrictor.
place. 5. If the tooth or teeth were replanted in the wrong socket or rotated, con-
6. If replantation at the accident site is not possible, or for other reasons sider repositioning the tooth/teeth into the proper location up to 48
when replantation of the avulsed tooth is not feasible (eg, an unconscious hours after the traumatic incident.
patient), place the tooth, as soon as possible, in a storage or transport 6. Stabilize the tooth for 2 weeks using a passive flexible splint such as
medium that is immediately available at the emergency site. This should wire of a diameter up to 0.016” or 0.4 mm32 bonded to the tooth and
be done quickly to avoid dehydration of the root surface, which starts to adjacent teeth. Keep the composite and bonding agents away from the
happen in a matter of a few minutes. In descending order of preference, gingival tissues and proximal areas. Alternatively, nylon fishing line (0.13-
milk, HBSS, saliva (after spitting into a glass for instance), or saline are 0.25 mm) can be used to create a flexible splint, using composite to bond


it to the teeth. Nylon (fishing line) splints are not recommended for 4. Examine the alveolar socket. Remove coagulum if necessary. If there is
children when there are only a few permanent teeth for stabilization of a fracture of the socket wall, reposition the fractured fragment with a
the traumatized tooth. This stage of development may result in loosening suitable instrument.
or loss of the splint.33 In cases of associated alveolar or jawbone fracture, 5. Replant the tooth slowly with slight digital pressure. The tooth should
a more rigid splint is indicated and should be left in place for about 4 not be forced back to place.
weeks. 6. Verify the correct position of the replanted tooth both clinically and
7. Suture gingival lacerations, if present. radiographically.
8. Initiate root canal treatment within 2 weeks after replantation (refer to 7. Stabilize the tooth for 2 weeks40 using a passive flexible wire of a diameter
Endodontic Considerations). up to 0.016” or 0.4 mm.32 Keep the composite and bonding agents away
9. Administer systemic antibiotics.34,35 (see: “Antibiotics”) from the gingival tissues and proximal areas. Alternatively, nylon fishing
10. Check tetanus status.36 (see: “Tetanus”) line (0.13-0.25 mm) can be used to create a flexible splint, with composite
1 1. Provide post-operative instructions. (see: “Patient instructions”) to bond it to the teeth. A more rigid splint is indicated in cases of alveolar
12. Follow up. (see: “Follow-up procedures”) or jawbone fracture and should be left in place for about 4 weeks.
8. Suture gingival lacerations, if present.
3.1.2 | The tooth has been kept in a physiologic storage medium or stored 9. Root canal treatment should be carried out within 2 weeks (refer to
in non-physiologic conditions, with the extra-oral dry time less than 60 Endodontic Considerations).
minutes 10. Administer systemic antibiotics.34,35 (see: “Antibiotics”)
Physiologic storage media include tissue culture media and cell transport 11. Check tetanus status.36 (see: “Tetanus”)
media. Examples of osmolality-balanced media are milk and Hanks’ Balanced 12. Provide post-operative instructions. (see: “Post-operative instructions”)
Salt Solution (HBSS). 13. Follow up. (see: “Follow-up procedures”)
1. If there is visible contamination, rinse the root surface with a stream of
saline or osmolality-balanced media to remove gross debris. Delayed replantation has a poor long-term prognosis.41 The periodontal
2. Check the avulsed tooth for surface debris. Remove any debris by gently ligament becomes necrotic and is not expected to regenerate. The expected
agitating it in the storage medium. Alternatively, a stream of saline can outcome is ankylosis-related (replacement) root resorption. The goal of
be used to briefly rinse its surface. replantation in these cases is to restore, at least temporarily, esthetics and
3. Put or leave the tooth in a storage medium while taking a history, exam- function while maintaining alveolar bone contour, width, and height. Therefore,
ining the patient clinically and radiographically, and preparing the patient the decision to replant a permanent tooth is almost always the correct deci-
for the replantation. sion even if the extra-oral dry time is more than 60 minutes. Replantation
4. Administer local anesthesia, preferably without a vasoconstrictor.37 will keep future treatment options open. The tooth can always be extracted,
5. Irrigate the socket with sterile saline. if needed, and at the appropriate point following prompt inter-disciplinary
6. Examine the alveolar socket. If there is a fracture of the socket wall, reassessment. Parents of pediatric patients should be informed that decoro-
position the fractured fragment into its original position with a suitable nation or other procedures such as autotransplantation might be necessary
instrument. later if the replanted tooth becomes ankylosed and infra-positioned, de-
7. Removal of the coagulum with a saline stream may allow better reposi- pending on the patient’s growth rate41-46 and the likelihood of eventual
tioning of the tooth. tooth loss. The rate of ankylosis and resorption varies considerably and can
8. Replant the tooth slowly with slight digital pressure. Excessive force be unpredictable.
should not be used to replant the tooth back into its original position.
9. Verify the correct position of the replanted tooth both clinically and radio- 3.2 | Treatment guidelines for avulsed permanent teeth with an open apex
graphically. 3.2.1 | The tooth has been replanted before the patient’s arrival at the
10. Stabilize the tooth for 2 weeks using a passive, flexible wire of a diameter clinic
up to 0.016” or 0.4 mm.32 Keep the composite and bonding agents away 1. Clean the area with water, saline, or chlorhexidine.
from the gingival tissues and proximal areas. Alternatively, nylon fishing 2. Verify the correct position of the replanted tooth both clinically and radio-
line (0.13-0.25 mm) can be used to create a flexible splint, using composite graphically.
to bond it to the teeth. Nylon (fishing line) splints are not recommended 3. Leave the tooth in the jaw (except where the tooth is malpositioned;
for children when there are only a few permanent teeth as stabilization the malpositioning needs to be corrected using slight digital pressure).
of the traumatized tooth may not be guaranteed. In cases of associated 4. Administer local anesthesia, if necessary, and preferably with no vasocon-
alveolar or jawbone fracture, a more rigid splint is indicated and should strictor.
be left in place for about 4 weeks. 5. If the tooth or teeth were replanted in the wrong socket or rotated, con-
11. Suture gingival lacerations, if present. sider repositioning the tooth/teeth into the proper location for up to 48
12. Initiate root canal treatment within 2 weeks after replantation (refer to hours after the trauma.
“Endodontic Considerations”).38,39 6. Stabilize the tooth for 2 weeks using a passive and flexible wire of a
13. Administer systemic antibiotics.34,35 (see: “Antibiotics”) diameter up to 0.016” or 0.4 mm.32 Short immature teeth may require a
14. Check tetanus status.36 (see: “Tetanus”) longer splinting time.47 Keep the composite and bonding agents away
15. Provide post-operative instructions. (see: “Post-operative instructions”) from the gingival tissues and proximal areas. Alternatively, nylon fishing
16. Follow up. (see: “Follow-up procedures”) line (0.13-0.25 mm) can be used to create a flexible splint, using compo-
site to bond it to the teeth. In cases of associated alveolar or jawbone
3.1.3 | Extra-oral dry time longer than 60 minutes fracture, a more rigid splint is indicated and should be left in place for 4
1. Remove loose debris and visible contamination by agitating the tooth in weeks.
physiologic storage medium, or with gauze soaked in saline. Tooth may be 7. Suture gingival lacerations, if present.
left in storage medium while taking a history, examining the patient clini- 8. Pulp revascularization, which can lead to further root development, is
cally and radiographically, and preparing the patient for the replantation. the goal when replanting immature teeth in children. The risk of external
2. Administer local anesthesia, preferably without vasoconstrictor. infection-related (inflammatory) root resorption should be weighed
3. Irrigate the socket with sterile saline. against the chances of revascularization. Such resorption is very rapid in


children. If spontaneous revascularization does not occur, apexification, 4. Irrigate the socket with sterile saline.
pulp revitalization/ revascularization,48,49 or root canal treatment should 5. Examine the alveolar socket. If there is a fracture of the socket wall,
be initiated as soon as pulp necrosis and infection is identified (refer to reposition the fractured segment with a suitable instrument.
Endodontic Considerations). 6. Replant the tooth slowly with slight digital pressure.
9. Administer systemic antibiotics.34,35 (see: “Antibiotics”) 7. Verify the correct position of the replanted tooth both clinically and
10. Check tetanus status.36 (see: “Tetanus”) radiographically.
11. Provide post-operative instructions. (see: “Post-operative instructions”) 8. Stabilize the tooth for 2 weeks using a passive and flexible wire of a di-
12. Follow up. (see: “Follow-up procedures”) ameter up to 0.016” or 0.4 mm.32 Keep the composite and bonding
agents away from the gingival tissues and proximal areas. Alternatively,
In immature teeth with open apices, there is a potential for spontaneous nylon fishing line (0.13-0.25 mm) can be used to create a flexible splint,
healing to occur in the form of new connective tissue with a vascular supply. with composite to bond it to the teeth. In cases of associated alveolar or
This allows continued root development and maturation. Hence, endodontic jawbone fracture, a more rigid splint is indicated and should be left for
treatment should not be initiated unless there are definite signs of pulp about 4 weeks.
necrosis and infection of the root canal system at follow-up appointments. 9. Suture gingival lacerations, if present.
10. Revascularization of the pulp space, which can lead to further root devel-
3.2.2 | The tooth has been kept in a physiologic storage medium or opment and maturation, is the goal when replanting immature teeth in
stored in non-physiologic conditions, and the extra-oral time has been children. The risk of external infection-related (inflammatory) root resorp-
less than 60 minutes tion should be weighed against the chances of revascularization. Such
Examples of physiologic or osmolality-balanced media are milk and HBSS. resorption is very rapid in children. If spontaneous revascularization does
1. Check the avulsed tooth and remove debris from its surface by gently not occur, apexification, pulp revitalization/revascularization, or root canal
agitating it in the storage medium. Alternatively, a stream of sterile saline treatment should be initiated as soon as pulp necrosis and infection is
or a physiologic medium can be used to rinse its surface. identified (refer to Endodontic Considerations).
2. Place or leave the tooth in a storage medium while taking the history, 11. Administer systemic antibiotics.34,35 (see: “Antibiotics”)
examining the patient clinically and radiographically and preparing the 12. Check tetanus status.36 (see: “Tetanus”)
patient for the replantation. 13. Provide post-operative instructions. (see: “Post-operative instructions”)
3. Administer local anesthesia, preferably without vasoconstrictor. 14. Follow up. (see: “Follow-up procedures”)
4. Irrigate the socket with sterile saline.
5. Examine the alveolar socket. Remove coagulum, if necessary. If there is Delayed replantation has a poor long-term prognosis.41 The periodontal
a fracture of the socket wall, reposition the fractured segment with a ligament becomes necrotic and is not expected to regenerate. The expected
suitable instrument. outcome is ankylosis-related (replacement) root resorption. The goal of re-
6. Replant the tooth slowly with slight digital pressure. plantation in these cases is to restore esthetics and function, at least tem-
7. Verify the correct position of the replanted tooth both clinically and porarily, while maintaining alveolar bone contour, width and height.
radiographically. Therefore, the decision to replant a tooth is almost always the correct decision
8. Stabilize the tooth for 2 weeks using a passive and flexible wire of a di- even if the extraoral time is more than 60 minutes. Replantation will keep
ameter up to 0.016” or 0.4 mm.32 Keep the composite and bonding agents future treatment options open. The tooth can always be extracted later if
away from the gingival tissues and proximal areas. Alternatively, nylon needed, and at the appropriate point following a prompt inter-disciplinary
fishing line (0.13-0.25 mm) can be used to create a flexible splint, with assessment. Parents should be informed that decoronation or other pro-
composite to bond it to the teeth. In cases of associated alveolar or jaw- cedures such as autotransplantation might be necessary if the replanted
bone fracture, a more rigid splint is indicated and should be left for tooth becomes ankylosed and infra-positioned depending on the patient’s
about 4 weeks. growth41-46 and the likelihood of tooth loss. The rate of ankylosis and re-
9. Suture gingival lacerations, if present. sorption varies considerably and can be unpredictable.
10. Revascularization of the pulp space, which can lead to further root dev-
elopment, is the goal when replanting immature teeth in children. The 4 | ANESTHETICS
risk of external infection-related (inflammatory) root resorption should The best treatment for an avulsed tooth is immediate replantation at the
be weighed against the chances of revascularization. Such resorption is site of the accident, which is usually not painful. While local anesthesia is
very rapid in children. If spontaneous revascularization does not occur, not available when teeth are replanted at the site of injury, once the patient
apexification, pulp revitalization/revascularization,48,49 or root canal treat- arrives at a dental or medical facility, pain control by means of local anes-
ment should be initiated as soon as pulp necrosis and infection is thesia is always recommended.50-55 There are concerns as to whether there
identified (refer to Endodontic Considerations). are risks of compromising healing by using a vasoconstrictor in the anesthetic
11. Administer systemic antibiotics.34,35 (see: “Antibiotics”) solution. However, there is little evidence to support omitting a vasocon-
12. Check tetanus status.36 (see: “Tetanus”) strictor in the oral and maxillofacial region. Regional anesthesia (eg, infra-
13. Provide post-operative instructions. (see: “Post-operative instructions”) orbital nerve block) may be considered as an alternative to infiltration
14. Follow up. (see: “Follow-up procedures”) anesthesia in more severe injury cases and must be determined by the
clinician’s experience of providing such block injections.51,52
3.2.3 | Extra-oral time longer than 60 minutes
1. Check the avulsed tooth and remove debris from its surface by gently 5 | SYSTEMIC ANTIBIOTICS
agitating it in the storage medium. Alternatively, a stream of saline can Even though the value of systemic administration of antibiotics is highly
be used to rinse its surface. questionable, the periodontal ligament of an avulsed tooth often becomes
2. Place or leave the tooth in a storage medium while taking the history, contaminated by bacteria from the oral cavity, the storage medium, or the
examining the patient clinically and radiographically and preparing the environment in which the avulsion occurred. Therefore, the use of systemic
patient for the replantation. antibiotics after avulsion and replantation has been recommended to prevent
3. Administer local anesthesia, preferably with no vasoconstrictor. infection-related reactions and to decrease the occurrence of inflammatory


root resorption.34,35 Additionally, the patient’s medical status or concomitant replanted tooth for optimal healing and prevention of further injury. They
injuries may warrant antibiotic coverage. In all cases, appropriate dosage should be advised to:
for the patient’s age and weight should be calculated. Amoxicillin or peni- 1. Avoid participation in contact sports.
cillin remain the first choices due to their effectiveness on oral flora and 2. Maintain a soft diet for up to 2 weeks, according to the tolerance of the
low incidence of side effects. Alternative antibiotics should be considered patient.65
for patients with an allergy to penicillin. The effectiveness of tetracycline 3. Brush their teeth with a soft toothbrush after each meal.
administered immediately after avulsion and replantation has been demon- 4. Use a chlorhexidine (0.12%) mouth rinse twice a day for 2 weeks.
strated in animal models.35 Specifically, doxycycline is an appropriate
antibiotic to use because of its antimicrobial, anti-inflammatory and anti- 10 | ENDODONTIC CONSIDERATIONS
resorptive effects. However, the risk of discoloration of permanent teeth When endodontic treatment is indicated (teeth with closed apex),17,73-81 treat-
must be considered before systemic administration of a tetracycline in ments hould be initiated within 2 weeks postreplantation. Endodontic treat-
young patients. Tetracycline or doxycycline are generally not recommended ment should always be undertaken after isolation with the dental dam. This
for patients under 12 years of age.56 may be achieved by placing the dental dam retainer on neighboring uninjured
teeth to avoid further trauma to the injured tooth/teeth. Calcium hydroxide
6 | TOPICAL ANTIBIOTICS is recommended as an intracanal medicament for up to 1 month followed
The effect of topical antibiotics placed on the root surface prior to replanta- by root canal filling.82,83 If a corticosteroid or corticosteroid/antibiotic mixture
tion with respect to pulp revascularization remains controversial.8,57,58 While is chosen to be used as an anti-inflammatory and anti-resorptive intracanal
animal studies have shown great potential,59-61 human studies have failed medicament, it should be placed immediately or shortly after replantation
to demonstrate improved pulp revascularization when teeth are soaked in and left in situ for at least 6 weeks.76,78,84 Medicaments should be carefully
topical antibiotics.62 Therefore, a specific antibiotic, duration of use, or applied to the root canal system with care to avoid placement in the crown
methods of application cannot be recommended based on human studies of the tooth. Some medicaments have been shown to discolor teeth, leading
(see future areas of research). to patient dissatisfaction.77
In teeth with open apices, spontaneous pulp space revascularization
7 | TETANUS may occur. Thus, root canal treatment should be avoided unless there is
Although most people receive tetanus immunization and boosters, it can- clinical or radiographic evidence of pulp necrosis and infection of the root
not be assumed that this is always the case.36,63,64 Refer the patient to a canal system on follow-up examinations. The risk of infection-related (inflam-
physician for evaluation of the need for a tetanus booster. matory) root resorption should be weighed against the chances of obtain-
ing pulp space revascularization. Such resorption is very rapid in children.
8 | STABILIZATION OF REPLANTED TEETH (SPLINTING) In cases where pulp necrosis and infection of the root canal system are
Avulsed teeth always require stabilization to maintain the replanted tooth diagnosed, root canal treatment, apexification or pulp space revascularization/
in its correct position, provide patient comfort and improve function.32,47,65-72 revitalization should be performed. In cases where ankylosis is expected and
Current evidence supports short-term, passive and flexible splints for stabi- decoronation is anticipated, proper consideration of the intracanal materials
lization of replanted teeth. Studies have shown that periodontal and pulp used and their duration is indicated.
healing are promoted if the replanted tooth is subjected to slight mobility
and function,66 achieved with stainless steel wire up to a diameter of 0.016” 11 | FOLLOW-UP PROCEDURES
or 0.4 mm32 or with nylon fishing line (0.13-0.25 mm), and bonded to the 11.1 | Clinical control
teeth with composite resin. Replanted permanent teeth should be stabilized Replanted teeth should be monitored clinically and radiographically at 2
for a period of 2 weeks depending on the length and degree of maturation weeks (when the splint is removed), 4 weeks, 3 months, 6 months, one year,
of the root. An animal study has shown that more than 60% of the mecha- and yearly thereafter for at least five years.2,6-9,25,26,85 Clinical and radiographic
nical properties of the injured PDL return within 2 weeks following injury.69 examination will provide information to determine the outcome. Evaluation
However, the likelihood of successful periodontal healing after replantation may include the findings described below.
is not likely to be affected by splinting duration.47 For open apex teeth where spontaneous pulp space revascularization is
Wire (or nylon line) and composite stabilization should be placed on the possible, clinical and radiographic reviews should be more frequent owing
labial surfaces to avoid occlusal interference and to enable palatal/lingual to the risk of infection-related (inflammatory) resorption and the rapid loss
access for endodontic procedures. Various types of wire (or nylon line) and of the tooth and supporting bone when this is not identified quickly. Evi-
acid etch bonded stabilization have been used to stabilize avulsed teeth dence of root and/or bone resorption anywhere around the circumference
as they allow good oral hygiene and they are well tolerated by patients.72 It of the root should be interpreted as infection-related (inflammatory) resorp-
is critically important to keep the composite and bonding agents away from tion. Radiographic absence of periodontal ligament space, the replacement
the marginal gingiva and interproximal areas to avoid plaque retention and of root structure by bone, together with a metallic sound to percussion,
secondary infection, and to allow relatively easy cleaning by the patient. should be interpreted as ankylosis-related (replacement) resorption. It is
The patient and parent should be advised that on removal of the splint, the worth noting that the two types of resorption may occur concurrently. For
injured tooth may be mobile. An additional week of splinting is appropriate these reasons, replanted teeth with an open apex should be monitored
only if excessive trauma from the opposing dentition might further trau- clinically and radiographically at 2 weeks (when the splint is removed), 1, 2,
matize the tooth or if the avulsed tooth is unable to remain in the correct 3, 6 months, one year, and yearly thereafter for at least five years.2,6-9,25,26,85
position. An assessment of this should be made after the splint is removed
and the occlusion checked. 1 1.2 | Favorable outcomes
1 1.2.1 | Closed apex
9 | PATIENT INSTRUCTIONS Asymptomatic, functional, normal mobility, no sensitivity to percussion, and
Patient compliance with follow-up visits and home care contributes to normal percussion sound. No radiolucencies and no radiographic evidence
satisfactory healing following an injury.2,24,25,27,29 Both patients and parents of root resorption. The lamina dura appears normal.
or guardians of young patients should be advised regarding care of the


11.2.2 | Open apex in dentistry and follows a robust consensus methodology and is underpinned
Asymptomatic, functional, normal mobility, no sensitivity to percussion, and by a systematic review of the outcomes used in the trauma literature.88 A
normal percussion sound. Radiographic evidence of continued root form- number of outcomes were identified as recurring throughout the different
ation and tooth eruption. Pulp canal obliteration is expected and can be injury types. These outcomes were then included as “generic”—that is re-
recognized radiographically sometime during the first year after the trauma. levant to all TDI. Injury-specific outcomes were also determined as those
It is considered to be the mechanism by which the “pulp” heals after outcomes related only to one or more particular TDI. Additionally, the study
replantation of avulsed immature permanent teeth.86 established what, how, when and by whom these outcomes should be
measured. Further information for each outcome is described in the original
11.3 | Unfavorable outcomes paper.87
11.3.1 | Closed apex Generic outcomes:
Patient may or may not have symptoms; presence of swelling or sinus tract; 1. Periodontal healing
the tooth may have excessive mobility or no mobility (ankylosis) with high- 2. Pulp space healing (for open apex teeth)
pitched (metallic) percussion sound. Presence of radiolucencies. Radiographic 3. Pain
evidence of infection-related (inflammatory) resorption, ankylosis-related 4. Discoloration
(replacement) resorption, or both. When ankylosis occurs in a growing 5. Tooth loss
patient, infra-position of the tooth is highly likely to create disturbances in 6. Quality of life
alveolar and facial growth over the short, medium and long term. 7. Esthetics (patient perception)
8. Trauma-related dental anxiety
11.3.2 | Open apex 9. Number of clinic visits
The patient may or may not have symptoms; presence of swelling or sinus
tract; the tooth may have excessive mobility or no mobility (ankylosis) with Injury-specific outcomes:
high-pitched percussion sound. In the case of ankylosis, the tooth may 1. Infra-occlusion
gradually become infra-positioned. Presence of radiolucencies. Radiographic
evidence of infection-related (inflammatory) resorption, ankylosis-related 14 | FUTURE ARE AS OF RESEARCH—TOPICS DISCUSSED BUT NOT
(replacement) resorption, or absence of continued root formation. When INCLUDED AS RECOMMENDATIONS IN THESE GUIDELINES
ankylosis occurs in a growing patient, infra-position of the tooth is highly Several promising treatment procedures for avulsed teeth have been dis-
likely to create disturbances of alveolar and facial growth over the short, cussed in the consensus group. Some of these treatment suggestions have
medium and long term. certain experimental evidence, and some are used in clinical practice. Accord-
ing to the working group members, there is currently insufficient weight or
12 | LONG-TERM FOLLOW-UP CARE (LOSS OF TOOTH OR INFRA-OCCLUSION) quality of clinical and/or experimental evidence for some of these methods
Follow-up care requires good coordination between the initial provider of to be recommended in these Guidelines. The group advocates further research
treatment and specialists in secondary care services (eg, an inter-disciplinary and documentation for the following:
team such as an orthodontist and pediatric dentist and/or endodontist) • Revascularization of the pulp space—see guidelines published by the
with the appropriate experience and training in the holistic management of American Association of Endodontists (AAE)89 and the European Society
complex dento-alveolar trauma. The team will benefit from other specialists of Endodontology (ESE).90
who will provide longer-term care such as a bonded bridge, a transplant, or • Optimal splint types and length of time relative to periodontal and pulp
an implant. In situations where access to an inter-disciplinary team may not healing.
be possible, dentists can only be expected to provide follow-up care and • Effect on healing when a local anesthetic containing vasoconstrictors is
treatment within their experience, training and competence. used.
Patients or parents and children need to be fully informed of the prog- • Effects of topical and systemic antibiotics on healing and root resorption.
nosis of an avulsed tooth as soon as possible. They should be fully engaged • Effect of intracanal corticosteroids on healing and root resorption.
in the decision-making process. Furthermore, the potential costs of and • Long-term development or establishment of the alveolar crest following
time required for different treatment options should be openly discussed. replantation and decoronation.
In cases where teeth are lost in the emergency phase after trauma, or • Effect of periodontal regeneration on the restoration of normal function.
will likely be lost later, discussions with appropriate colleagues who have • Periodontal healing following tooth replantation.
expertise with managing these cases are prudent, especially in growing • Home care following tooth replantation.
patients. Ideally, these discussions should take place before the tooth shows
signs of infra-position. Appropriate treatment options may include decor- CONFLICT OF INTEREST
onation, autotransplantation, a resin-retained bridge, a removable partial The authors confirm that they have no conflict of interest.
denture or orthodontic space closure with or without composite resin modi-
fication. Treatment decisions are based on a full discussion with the patient ETHICAL APPROVAL
or the child and parents and the clinician’s expertise with the aim to keep No ethic approval was required for this paper.
all options open until maturity is reached. The decision to perform decor-
onation is made when the ankylosed tooth shows evidence of infra-occlusion DISCLAIMER
that is deemed esthetically unacceptable and cannot be corrected by These guidelines are intended to provide information for healthcare provid-
simple restorative treatment.41,45 After growth is completed, implant treatment ers caring for patients with dental injuries. They represent the current best
can be considered. Readers are referred to relevant textbooks and journal evidence based on literature research and professional opinion. As is true for
articles for further reading regarding these procedures. all guidelines, the healthcare provider must use clinical judgment dictated
by the conditions present in any given traumatic situation. The IADT does
13 | CORE OUTCOME SET not guarantee favorable outcomes from following the Guidelines, but using
The IADT recently developed a core outcome set (COS) for traumatic dental the recommended procedures can maximize the chances of success.
injuries (TDI) in children and adults.87 This is one of the first COS developed


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Georgios Tsilingaridis https://orcid.org/0000-0001-5361-5840
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Eva Lauridsen https://orcid.org/0000-0003-0859-7262 et al. International Association of Dental Traumatology guidelines for
Anne O’Connel https://orcid.org/0000-0002-1495-3983 the management of traumatic dental injuries: 2. Avulsion of perma-
Marie Therese Flores https://orcid.org/0000-0003-2412-190X nent teeth. Dent Traumatol. 2012;28:88–96.
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Peter F. Day https://orcid.org/0000-0001-9711-9638
Sigurdsson A, et al. International Association of Dental Traumatology
Bill Kahler https://orcid.org/0000-0002-4181-3871 guidelines for the management of traumatic dental injuries: 1. Fractures
Liran Levin https://orcid.org/0000-0002-8123-7936 and luxations of permanent teeth. Dent Traumatol. 2012;28:2–12.
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International Association of Dental Traumatology guidelines for the
management of traumatic dental injuries: General introduction. Dent
Traumatol. 2020;36:309–13.


ENDORSEMENTS: INJURIES IN PRIMARY DENTITION

Injuries: 3. Injuries in the Primary Dentition
How to Cite: Day PF, Flores MT, O’Connell AC, et al. International
Association of Dental Traumatology guidelines for the management
of traumatic dental injuries: 3. Injuries in the primary dentition.
2020 Dent Traumatol 2020;36:343-359. https://doi.org/10.1111/edt.12576.
Authors
Peter F. Day1 • Marie Therese Flores2 • Anne C. O’Connell3 • Paul V. Abbott4 • Georgios Tsilingaridis5,6 Ashraf F. Fouad7 • Nestor Cohenca8 • Eva Lauridsen9 • Cecilia
Bourguignon10 • Lamar Hicks1 1 • Jens Ove Andreasen12 • Zafer C. Cehreli13 • Stephen Harlamb14 • Bill Kahler15 • Adeleke Oginni16 • Marc Semper17 • Liran Levin18
Abstract
Traumatic injuries to the primary dentition present special problems that often require far different management when compared to that
used for the permanent dentition. The International Association of Dental Traumatology (IADT) has developed these Guidelines as a con-
sensus statement after a comprehensive review of the dental literature and working group discussions. Experienced researchers and clinicians
from various specialties and the general dentistry community were included in the working group. In cases where the published data did
not appear conclusive, recommendations were based on the consensus opinions or majority decisions of the working group. They were then
reviewed and approved by the members of the IADT Board of Directors. The primary goal of these Guidelines is to provide clinicians with
an approach for the immediate or urgent care of primary teeth injuries based on the best evidence provided by the literature and expert
opinions. The IADT cannot, and does not, guarantee favorable outcomes from strict adherence to the Guidelines; however, the IADT believes
their application can maximize the probability of favorable outcomes. (Dental Traumatology 2020;36:343-359; doi: 10.1111/edt.12576) Received
May 19, 2020 | Accepted May 19 2020.
1 | INTRODUCTION
Injuries to children are a major threat to their health, and they are generally
a neglected public health problem.1 For children, aged 0-6 years, oral injuries
account for 18% of all physical injuries and the mouth is the second most
1
School of Dentistry, University of Leeds and Community Dental Service Bradford District Care common area of the body to be injured.2 A recent meta-analysis on trau-
NHS Trust, Leeds, UK. 2Department of Pediatric Dentistry, Faculty of Dentistry, Universidad de
matic dental injuries (TDIs) reveals a world prevalence of 22.7% affecting the
Valparaíso, Valparaíso, Chile. 3Paediatric Dentistry, Dublin Dental University Hospital, Trinity
College Dublin, The University of Dublin, Dublin, Ireland. 4UWA Dental School, University of
primary teeth.3 Repeated TDIs are also frequently seen in children.4
Western Australia, Nedlands, WA, Australia. 5Division of Orthodontics and Pediatric Dentistry, Unintentional falls, collisions, and leisure activities are the most common
Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden. 6Center for Pediatric reasons for TDIs, especially as children learn to crawl, walk, run, and embrace
Oral Health Research, Stockholm, Sweden. 7Adams School of Dentistry, University of North their physical environment.5 They most commonly occur between 2 and
Carolina, Chapel Hill, NC, USA. 8Department of Pediatric Dentistry, University of Washington 6 years of age4–7 with injuries to periodontal tissues occurring most fre-
and Seattle Children’s Hospital, Seattle, WA, USA. 9Resource Center for Rare Oral Diseases, Co- quently.6,8 Children with these injuries present to many healthcare settings,
penhagen University Hospital, Copenhagen, Denmark. 10Specialist Private Practice, Paris, France.
11
including general dental practitioners, emergency medical services, pharma-
Division of Endodontics, University of Maryland School of Dentistry, UMB, Baltimore, MD,
USA. 12Department of Oral and Maxillofacial Surgery, Resource Centre for Rare Oral Diseases,
cists, community dental clinics, and specialist dental services. Consequently,
University Hospital in Copenhagen (Rigshospitalet), Copenhagen, Denmark. 13Department of each service provider needs to have the appropriate knowledge, skills, and
Pediatric Dentistry, Faculty of Dentistry, Hacettepe University, Ankara, Turkey. 14Faculty of training in how to care for children with TDIs to their primary dentition.
Medicine and Health, The University of Sydney, Sydney, NSW, Australia. 15School of Dentistry, The primary teeth Guidelines contain recommendations for the diagnosis
The University of Queensland, St Lucia, Qld, Australia. 16Faculty of Dentistry, College of Health and management of traumatic injuries to the primary dentition, assuming
Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria. 17Specialist Private Practice, Bremen, the child is medically healthy with a sound and caries-free primary dentition.
Germany. 18Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
Management strategies may change where multiple teeth are injured. Many
Dentistry, University of Alberta, 5-468 Edmonton Clinic Health Academy, 11405-87 Avenue NW,
articles have contributed to the content of these Guidelines and the treat-
5th Floor, Edmonton, AB T6G 1C9, Canada. ment tables (1-12) and these articles are not mentioned elsewhere in this
Email: liran@ualberta.ca introductory text.9–15


1.1 | Initial presentation and minimizing anxiety to the child and parent treatment is not indicated for discolored teeth unless there are clinical or
Management of TDIs in children is distressing for both the child and the radiographic signs of infection of the root canal system.18,33
parents. It can also be challenging for the dental team. A TDI in the primary Every effort has been made in these Guidelines to reduce the number
dentition often may be the reason for the child’s first visit to the dentist. of radiographs needed for accurate diagnosis, thus minimizing a child’s ex-
Minimizing anxiety for the child and parents, or other caregivers, during the posure to radiation. For essential radiographs, radiation protection includes
initial visit is essential. At this young age, the child may resist co-operating for the use of a thyroid collar where the thyroid is in the path of the primary X-ray
an extensive examination, radiographs, and treatment. Knee-to-knee exami- beam and a lead apron for when parents are holding the child. Radiation-
nation can be helpful in examining a young child. Information about how associated risks for children are a concern as they are substantially more
to undertake an examination of a child with a TDI involving their primary susceptible to the effects of radiation exposure for the development of most
dentition can be found in current textbooks16–18 or can be viewed in the fol- cancers than adults. This is due to their longer life expectancy and the acute
lowing video (https://tinyurl.com/kneetokneeexamination). Wherever possible, radiosensitivity of some developing organs and tissues.34,35 Therefore, clini-
the acute and follow-up dental care should be provided by a child- cians should question each radiograph they take and cognitively ask whether
oriented team that has experience and expertise in the management of additional radiographs will positively affect the diagnosis or treatment pro-
pediatric oral injuries. These teams are best placed to access specialist diag- vided for the child. Clinicians must work within the ALARA (As Low As
nostic and treatment services, including sedation and general anesthesia, Reasonably Achievable) principles to minimize the radiation dose. The use of
and pain management for the prevention or minimization of suffering.19 CBCT following TDI in young children is rarely indicated.36
1.2 | A structured approach 1.6 | Diagnosis

It is essential that clinicians adopt a structured approach to managing trau- A careful and systematic approach to diagnosis is essential. Clinicians should
matic dental injuries. This includes history taking, undertaking the clinical identify all injuries to each tooth including both hard tissues injuries (eg,
examination, collecting test results, and how this information is recorded. fractures) and periodontal injuries (eg, luxations). When concomitant injuries
The literature shows that the use of a structured history at the initial consul- occur in the primary dentition following extrusion and lateral luxation in-
tation leads to a significant improvement in the quality of the trauma records juries, they have a detrimental impact on pulp survival.27 The accompanying
involving the permanent dentition5,20. There are a variety of structured his- tables (1-12) and the trauma pathfinder diagram (www.dentaltraumaguide.org)
tories available in current textbooks16–18 or used at different specialist cen- help clinicians identify all possible injuries for each injured tooth.
ters.21,22 Extra-oral and intra-oral photographs act as a permanent record of
the injuries sustained and are strongly recommended. 1.7 | Intentional (non-accidental) injuries
Dental and facial trauma can occur in cases of intentional injuries. Clinicians
1.3 | Initial assessment should check whether the history of the accident and the injuries sustained
Elicit a careful medical, social (including those who attend with the child), are consistent or match. In situations where there is suspicion of abuse,
dental, and accident history. Thoroughly examine the head and neck and prompt referral for a full physical examination and investigation of the
intra-orally for both bony and soft tissue injuries.17,18 Be alert to concomitant incident should be arranged. Referral should follow local protocols, which is
injuries including head injury, facial fractures, missing tooth fragments, or beyond the scope of these Guidelines.
lacerations. Seek a medical examination if necessary.
1.8 | Impact of orofacial and primary tooth trauma on the permanent
1.4 | Soft tissue injuries dentition
It is essential to identify, record, and diagnose extra-oral and intraoral soft There is a close spatial relationship between the apex of the primary tooth
tissue injuries.18,23 The lips, oral mucosa, attached and free gingivae, and the root and the underlying permanent tooth germ. Tooth malformation, im-
frenula should be checked for lacerations and hematomas. The lips should pacted teeth, and eruption disturbances in the developing permanent den-
be examined for possible embedded tooth fragments. The presence of a tition are some of the consequences that can occur following injuries to
soft tissue injury is strongly associated with the pursuit of immediate care. primary teeth and the alveolar bone.37–43 Intrusion and avulsion injuries are
Such injuries are most commonly found in the 0- to 3-year age group.24 most commonly associated with the development of anomalies in the per-
Management of soft tissues, beyond just first aid, should be provided by a manent dentition.37–42
child-oriented team with experience in pediatric oral injuries. Parental en- For intrusive and lateral luxation injuries, previous Guidelines have recom-
gagement with the homecare for soft tissue injuries to the gingivae is criti- mended the immediate extraction of the traumatized primary tooth if the
cal and will influence the outcomes for healing of the teeth and soft tissues. direction of displacement of the root is toward the permanent tooth germ.
Parental homecare instructions for intra-oral soft tissue injuries are described This action is no longer advised due to (a) evidence of spontaneous re-
later in these Guidelines. eruption for intruded primary teeth,8,10,26,43–45 (b) the concern that further
damage may be inflicted on the tooth germ during extraction, and (c) the
1.5 | Tests, crown discoloration, and radiographs lack of evidence that immediate extraction will minimize further damage to
Extra-oral and intra-oral photographs are strongly recommended. the permanent tooth germ.
Pulp sensibility tests are unreliable in primary teeth and are therefore It is very important to document that parents have been informed
not recommended. about possible complications to the development of the permanent teeth,
Tooth mobility, color, tenderness to manual pressure, and the position or especially following intrusion, avulsion, and alveolar fractures.
displacement should be recorded.
The color of injured and uninjured teeth should be recorded at each clinic 1.9 | Management strategy for injuries to the primary dentition
visit. Discoloration is a common complication following luxation injuries.8,25–27 In general, there is limited evidence to support many of the treatment options
This discoloration may fade, and the tooth may regain its original shade over in the primary dentition. Observation is often the most appropriate option in
a period of weeks or months.8,28–30 Teeth with persistent dark discoloration the emergency situation unless there is risk of aspiration, ingestion, or inter-
may remain asymptomatic clinically and radiographically normal, or they ference with the occlusion. This conservative approach may reduce additional
may develop apical periodontitis (with or without symptoms).31,32 Root canal suffering for the child18 and the risk of further damage to the permanent
dentition.18,46,47






















A summary of the management of TDIs in the primary dentition in- be advised regarding care of the injured tooth/teeth and the prevention of
cludes the following: further injury by supervising potentially hazardous activities. Clean the
• A child’s maturity and ability to cope with the emergency situation, the affected area with a soft brush or cotton swab and use alcohol-free chlor-
time for shedding of the injured tooth, and the occlusion are all important hexidine gluconate 0.12% mouth rinse applied topically twice a day for one
factors that influence treatment. week to prevent accumulation of plaque and debris and to reduce the
• It is critical that parents are given appropriate advice on how best to man- bacterial load. Care should be taken when eating not to further traumatize
age the acute symptoms to avoid further distress.48,49 Luxation injuries, the injured teeth while encouraging a return to normal function as soon as
such as intrusion and lateral luxation, and root fractures may cause severe possible.
pain. The use of analgesics such as ibuprofen and/or acetaminophen Parents or caregivers should be advised about possible complications
(paracetamol) is recommended when pain is anticipated. that may occur, such as swelling, increased mobility, or a sinus tract. Children
• Minimizing dental anxiety is essential. Provision of dental treatment de- may not complain about pain, but infection may be present. Parents or care-
pends on the child’s maturity and ability to cope. Various behavioral givers should watch for signs of infection such as swelling of the gums. If
approaches are available50–51 and have been shown to be effective for present, they should take the child to a dentist for treatment. Examples of
managing acute procedures in an emergency situation.52,53 TDIs and their unfavorable outcomes are found in the table for each injury (Tables 1-12).
treatment have the potential to lead to both post-traumatic stress
disorder and dental anxiety. The development of these conditions in 1.13 | Training, skills, and experience for teams managing the follow-up
young children is a complex issue54,55 with little research specifically care
examining either condition following TDIs in the primary dentition. During the follow-up phase of treatment, dental teams caring for children
However, evidence from the wider dental literature suggests that the with complex injuries to the primary dentition should have specialist train-
multi-factorial nature of dental anxiety, its fluctuating nature, and the ing, experience, and skills. These attributes enable the members of the team
role of dental extractions are exacerbating factors.56–58 Where possible, to respond appropriately to the medical, physical, emotional, and devel-
avoidance of dental extractions, especially at the acute or initial visit, is opmental needs of children and their families. In addition, skills within the
a reasonable strategy. team should also encompass health promotion and access to specialist
• Where appropriate and the child’s cooperation allows, options that main- diagnostic and treatment services including sedation, general anesthesia, and
tain the child’s primary dentition should be the priority.59 Discussions overall pain management for the prevention or minimization of suffering.19
with parents about the different treatment options should include the
potential for further treatment visits and consideration for how best 1.14 | Prognosis
to minimize the impact of the injury on the developing permanent Factors relating to the injury and subsequent treatment may influence pulp
dentition.60 and periodontal outcomes, and they should be carefully recorded. These
• For crown and crown-root fractures involving the pulp, root fractures, prognostic factors need to be carefully collected at both the initial consulta-
and luxation injuries, rapid referral within several days to a child-oriented tion and follow-up visits. This is most likely achieved using the structured
team that has experience and expertise in the management of dental history form described previously. The dental literature and appropriate
injuries in children is essential. websites (eg, www.dentaltraumaguide.org) provide clinicians with useful in-
• Splinting is used for alveolar bone fractures40,61 and occasionally may be formation on the probable pulp and periodontal prognosis. These sources of
needed in cases of root fractures62 and lateral luxations.62 information can be invaluable when having conversations with the parents
or caregivers and the child.
1.10 | Avulsed primary teeth
An avulsed primary tooth should not be replanted. Reasons include a signifi- 1.15 | Core outcome set
cant treatment burden (including replantation, splint placement and removal, The International Association for Dental Traumatology (IADT) recently devel-
root canal treatment) for a young child as well as the potential of causing oped a core outcome set (COS) for traumatic dental injuries (TDIs) in children
further damage to the permanent tooth or to its eruption.40,41,63,64 However, and adults.65 This is one of the first COS developed in dentistry and is under-
the most important reason is to avoid a medical emergency resulting from pinned by a systematic review of the outcomes used in the trauma literature
aspiration of the tooth. Careful follow up is required to monitor the develop- and follows a robust consensus methodology.66 Some outcomes were iden-
ment and eruption of the permanent tooth. Refer to the accompanying tified as recurring throughout the different injury types. These outcomes
table () for specific guidance. were then identified as “generic” (ie, relevant to all TDIs). Injury-specific
outcomes were also determined as those outcomes related only to one or
1.11 | Antibiotics and Tetanus more individual TDIs. Additionally, the study established what, how, when,
There is no evidence for recommending the use of systemic antibiotics in and by whom these outcomes should be measured. Table 1 in the General
the management of luxation injuries in the primary dentition. However, Introduction section67 of the Guidelines shows the generic and injury-
antibiotic use does remain at the discretion of the clinician when TDIs are specific outcomes to be recorded at the follow-up review appointments
accompanied by soft tissue and other associated injuries or significant recommended for the different traumatic injuries. Further information for
surgical intervention is required. Finally, the child’s medical status may each outcome is described in the original article.65
warrant antibiotic coverage. The child’s pediatrician should be contacted
where questions arise in these situations. CONFLICT OF INTEREST
A tetanus booster may be required if environmental contamination of The authors declare there is no competing interest for the above manuscript.
the injury has occurred. If in doubt, refer to a medical practitioner within Images courtesy of the Dental Trauma Guide.
48 hours.
ETHICAL STATEMENT
1.12 | Parental instructions for homecare No ethics approval was required for this paper
Successful healing following an injury to the teeth and oral tissues depends
on good oral hygiene. To optimize healing, parents or caregivers should


ORCID the teeth, 5th edn. Copenhagen, Denmark: Wiley Blackwell; 2019. p.
Peter F. Day https://orcid.org/0000-0001-9711-9638 295–326.
Marie Therese Flores https://orcid.org/0000-0003-2412-190X 18. Flores MT, Holan G, Andreasen JO, Lauridsen E. Injuries to the primary
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Paul V. Abbott https://orcid.org/0000-0001-5727-4211 Denmark: Wiley Blackwell; 2019. p. 556–88.
Georgios Tsilingaridis https://orcid.org/0000-0001-5361-5840 19. World Medical Association. Declaration of Ottawa on Child Health.
Ashraf F. Fouad https://orcid.org/0000-0001-6368-1665 2009; https://www.wma.net/policies-post/wma-declaration-of-ottawa-on-
Nestor Cohenca https://orcid.org/0000-0002-0603-5437 child-health/. Accessed June 4, 2020.
20. Day PF, Duggal MS. A multicentre investigation into the role of struc-
Eva Lauridsen https://orcid.org/0000-0003-0859-7262
tured histories for patients with tooth avulsion at their initial visit to
Cecilia Bourguignon https://orcid.org/0000-0003-2753-649X a dental hospital. Dent Traumatol. 2003;19:243–7.
Bill Kahler https://orcid.org/0000-0002-4181-3871 21. Day PF, Duggal MS. The role for ‘reminders’ in dental traumatology: 1.
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ENDORSEMENTS: CLEFT LIP / PALATE / CRANIOFACIAL ANOMALIES
Policy on the Management of Patients with Cleft

Lip / Palate and Other Craniofacial Anomalies
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Policy on the
2019 management of patients with cleft lip/palate and other craniofacial
anomalies. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
The American Academy of Pediatric Dentistry (AAPD), in its 3. The optimal time for the first evaluation is within
efforts to promote optimal health for children with cleft lip/ the first few weeks of life and, whenever possible,
palate and other craniofacial anomalies, endorses the current within the first few days. However, referral for team
statements of the American Cleft Palate-Craniofacial Associa- evaluation and management is appropriate for patients
tion (ACPA).1 of any age.1
A child born with cleft lip/palate or other craniofacial 4. From the time of first contact with the child and
anomalies has multiple and complex problems, including early family, every effort must be made to assist the family
feeding and nutritional concerns, middle ear disease, hearing in adjusting to the birth of a child with a craniofacial
deficiencies, deviations in speech and resonance, dentofacial anomaly and the consequent demands and stress
and orthodontic abnormalities, and psychosocial adjustment placed upon that family.1
problems. 5. Parents/caregivers must be given information about
Reports by the U.S. Surgeon General2,3 on children with recommended treatment procedures, options, risk fac-
special needs issued in 1987 and 2005 stressed that the care tors, benefits, and costs to assist them in: (1) making
of these children should be comprehensive, coordinated, cul- informed decisions on the child’s behalf, and (2) pre-
turally sensitive, specific to the needs of the individual, and paring the child and themselves for all recommended
readily accessible. Recognizing that children with clefts and procedures. The team should actively solicit family
other craniofacial anomalies have special needs, the Maternal participation and collaboration in treatment plan-
and Child Health Bureau in 1991 provided funding to ACPA ning.1,4 When the child is mature enough to do so, he
to develop parameters of care for these patients through a or she should also participate in treatment decisions.1
series of consensus conferences among a multidisciplinary 6. Treatment plans should be developed and imple-
group of specialists.1 In addition, the ACPA joined with the mented on the basis of team recommendations.1
Cleft Palate Foundation to create standards for approval of 7. Care should be coordinated by the team, but should
teams to ensure that care is provided in a coordinated and be provided at the local level whenever possible; how-
consistent manner, including an appropriate sequence of ever, complex diagnostic or surgical procedures should
evaluations and treatment for the patient’s overall develop- be restricted to major centers with appropriate treat-
mental, medical, and psychological needs.4 ment facilities and experienced care providers.
As part of the parameters1 and standards4, several funda- 8. It is the responsibility of each team to be sensitive to
mental principles were identified as critical to optimal cleft/ linguistic, cultural, ethnic, psychosocial, economic, and
craniofacial care. These principles are: physical factors that affect the dynamic relationship
1. Management of patients with craniofacial anomalies between the team, the patient, and his/her family.1
is best provided by an interdisciplinary team of spe- 9. It is the responsibility of the team to monitor both
cialists.1 These teams are composed of qualified health short-term and long-term outcomes. Thus, longitu-
professionals from medical, surgical, dental, and allied dinal follow up of patients, including appropriate
health fields working together in a coordinated sys- documentation and record-keeping, is essential.1
tem. A designated patient care coordinator should 10. Evaluation of treatment outcomes must take into
be included in the team to assist in coordinated care account the satisfaction and psychosocial well-being
for patients and their families/caregivers.4 of the patient, as well as effects on growth, function,
2. Optimal care for patients with craniofacial anomalies and appearance.1
is provided by teams that see sufficient numbers of
these patients each year to maintain clinical expertise
ABBREVIATIONS
in diagnosis and treatment.
AAPD: American Academy Pediatric Dentistry. ACPA: American Cleft
Palate-Craniofacial Association.

ENDORSEMENTS: CLEFT LIP / PALATE / CRANIOFACIAL ANOMALIES
Patients with craniofacial anomalies require dental care 7. While continuous active orthodontic treatment from
throughtout life as a direct result of their condition and as an early mixed dentition to permanent dentition should
integral part of the treatment process. A dental home should be avoided, each stage of orthodontic therapy may
be established within six months of eruption of the first tooth be followed by retention and regular observation.
and no later than 12 months of age.5 It includes oral health Orthodontic retention for the permanent dentition
examinations, caries control, and preventive, restorative, and may extend into adulthood.
prosthetic dental treatment as needed. Patients should be 8. For some patients with craniofacial anomalies, func-
closely monitored for periodontal disease and anomalies in tional orthodontic appliances may be indicated.
dentition and eruption. The condition of the developing 9. For patients with craniofacial anomalies, orthodontic
dentition and supporting tissues, with counseling regarding treatment may be needed in conjunction with sur-
early oral hygiene and prevention of early childhood caries, gical correction (and/or distraction osteogenesis) of
is essential. Prosthetic appliances such as an obturator may the facial deformity.
help to close a fistula or aid in speech. Orthodontic treatment 10. Congenitally missing teeth may be replaced with a
is also an integral part of the habilitative process and often removable appliance, fixed restorative bridgework, or
takes place in phases. The skeletal and dental components osseointegrated implants.
should be regularly evaluated. When indicated, orthodontic 11. Patients should be closely monitored for dental and
treatment prepares a child for alveolar bone grafting of the periodontal disease.
cleft maxilla, correcting malocclusions, and jaw surgery.1 As 12. Prosthetic obturation of palatal fistulae may be
members of the interdisciplinary team of physicians, dentists, necessary in some patients.
speech-language pathologists, and other allied health profes- 13. A prosthetic speech device may be used to treat
sionals, pediatric dentists should provide dental services in velopharyngeal inadequacy in some patients.
close cooperation with their orthodontic, oral and maxillofacial
surgery, and prosthodontic colleagues.1,4 All dental specialists References
should ensure1: 1. American Cleft Palate-Craniofacial Association. Param-
1. Consultation with an appropriate dental specialist eters for Evaluation and Treatment of Patients with Cleft
should be made for cleft lip taping and or pre- Lip/Palate or Other Craniofacial Differences. Chapel Hill,
surgical orthopedics including, but not limited to, N.C.: The Maternal and Child Health Bureau, Health
nasal alveolar molding. A craniofacial orthodontist Resources and Services Administration, U.S. Public
(or appropriately-trained clinician) who can discuss Health Service, DHHS; January 2018. Grant # MCJ-
with the family the types of infant orthopedic services 425074. Available at: “https://acpa-cpf.org/team-care/
available and the rationale for using infant ortho- standardscat/parameters-of-care/”. Accessed October
pedics prior to initial cleft lip repair is necessary.
2. Dental radiographs, cephalometric radiographs, and citation.org/73es0ax0L”)
®
other imaging modalities as indicated should be 2. U.S. Department of Health and Human Services. A
utilized to evaluate and monitor dental and facial Report of the Surgeon General: Children with Special
growth and development. Health Care Needs. Rockville, Md.: Office of Maternal
3. Diagnostic records, including properly occluded den- and Child Health, U.S. Department of Health and
tal study models, should be collected at appropriate Human Services; 1987.
intervals for patients at risk for developing maloc- 3. U.S. Department of Health and Human Services. The
clusion or maxillary-mandibular discrepancies. Surgeon General’s Call to Action to Improve the Health
4. As the primary dentition erupts, the team evaluation and Wellness of Persons with Disabilities. Rockville,
should include a dental examination and, if such Md.: U.S. Department of Health and Human Services,
services are not already being provided, referral to Office of the Surgeon General; 2005.
appropriate providers for caries control, preventive 4. American Cleft Palate-Craniofacial Association Commis-
measures, restorative care, and space management. sion on Approval of Teams. Standards for Approval of
5. Before the primary dentition has completed eruption, Cleft Palate and Craniofacial Teams. American Cleft
the skeletal and dental components should be evalu- Palate-Craniofacial Association; 2016. Available at:
ated to determine if a malocclusion is present or “https://acpa-cpf.org/wp-content/uploads/2017/06/
developing. standards.pdf ”. Accessed October 11, 2019.
6. Depending upon the specific goals to be accomplished 5. American Academy of Pediatric Dentistry. Policy on
and also upon the age at which the patient is initially dental home. Pediatr Dent 2018;40(6):29-30.
evaluated, orthodontic management of the maloc-
clusion may be performed in the primary, mixed, or
permanent dentition. In some cases, orthodontic
treatment may be necessary in all three stages.

ENDORSEMENTS: PERIODONTAL DISEASES
Periodontal Diseases of Children and Adolescents

How to Cite: Research, Science and Therapy Committee Guidelines
of the American Academy of Periodontology. Periodontal diseases of
2004 children and adolescents. J Periodontol 2003;74:1696-1704.
Originating Group
American Academy of Periodontology – Research, Science and
Therapy Committee
Abstract
This paper was prepared by the Research, Science and Therapy Committee of the American Academy of Periodontology and is intended for
the information of the dental profession and the public. It represents a brief summary of the current state of knowledge about periodontal
diseases in children and adolescents. J Periodontol 2003;74(11):1696-1704.
Epidemiologic studies indicate that gingivitis of varying se- common in children.1-19,25 Although the microbiology of this
verity is nearly universal in children and adolescents.1-19 These disease has not been completely characterized, increased subgin-
studies also indicate that the prevalence of destructive forms gival levels of Actinomyces sp., Capnocytophaga sp., Leptotrichia
of periodontal disease is lower in young individuals than in sp., and Selenomonas sp. have been found in experimental
adults. Epidemiologic surveys in young individuals have been gingivitis in children when compared to gingivitis in adults.
performed in many parts of the world and among individuals These species may therefore be important in its etiology and
with a widely varied background. For the most part, these pathogenesis.26,27
surveys indicated that loss of periodontal attachment and Normal and abnormal fluctuation in hormone levels,
supporting bone is relatively uncommon in the young but including changes in gonadotrophic hormone levels during
that the incidence increases in adolescents aged 12 to 17 when the onset of puberty, can modify the gingival inflammatory
compared to children aged five to 11.15-22 In general, in the response to dental plaque.28,29 Similarly, alterations in insulin
United States, epidemiologic studies indicate that the preval- levels in patients with diabetes can affect gingival health.28,29 In
ence of severe attachment loss on multiple teeth among children both situations, there is an increased inflammatory response to
and young adults is approximately 0.2 to 0.5 percent.23 Despite plaque.28,29 However, the gingival condition usually responds
this low prevalence, children and adolescents should receive to thorough removal of bacterial deposits and improved daily
periodic periodontal evaluation as a component of routine oral hygiene.28,29
dental visits.
On October 30-November 2, 1999, the American Acade- Periodontitis
my of Periodontology assembled an International Workshop Aggressive periodontitis, chronic periodontitis, and periodon-
for a Classification of Periodontal Diseases and Conditions, titis as a manifestation of systemic diseases
which resulted in a new classification.24 Periodontal diseases Children and adolescents can have any of the several forms
discussed here will reflect the new classification system. Cli- of periodontitis as described in the proceedings of the 1999
nically distinct periodontal infections that can affect young International Workshop for a Classification of Periodontal
individuals include: 1) dental plaque-induced gingival diseases; Diseases and Conditions (aggressive periodontitis, chronic
2) chronic periodontitis; 3) aggressive periodontitis; 4) perio- periodontitis, and periodontitis as a manifestation of systemic
dontitis as a manifestation of systemic diseases; and 5) necro- diseases). However, chronic periodontitis is more common in
tizing periodontal diseases. adults, while aggressive periodontitis may be more common
in children and adolescents.24
Dental plaque-induced gingival diseases
Gingivitis associated with dental plaque only and gingival
diseases modified by systemic factors associated with the
endocrine system This position paper was developed under the direction of the Research, Science
Gingivitis characterized by the presence of gingival inflamma- * and Therapy Committee and approved by the Board of Trustees of the American
tion without detectable loss of bone or clinical attachment is Academy of Periodontology in August 2003.

© 2003 American Academy of Periodontology. J Periodontol 2003;74:1696-1704. Available at: “https://doi.org/10.1902/jop.2003.74.11.1696”.
The Journal of Periodontology is published monthly for the American Academy of Periodontology by John Wiley and Sons.

The primary features of aggressive periodontitis include a the susceptibility of individuals to LAgP is unknown, but it is
history of rapid attachment and bone loss with familial aggre- possible that they play a role in the clinical course of disease
gation. Secondary features include phagocyte abnormalities in some patients. Indeed, in some cases exhibiting phagocyte
and a hyperresponsive macrophage phenotype.24 Aggressive abnormalities, neutrophil defects may still be present after treat-
periodontitis can be localized or generalized. Localized aggressive ment.77 Molecular markers of LAgP can include an abnormally
periodontitis (LAgP) patients have interproximal attachment low number of chemoattractant receptors78-81 and an abnormally
loss on at least two permanent first molars and incisors, with low amount of another cell surface glycoprotein designated
attachment loss on no more than two teeth other than first GP-110.82,83 Adherence receptors on neutrophils and monocytes,
molars and incisors. Generalized aggressive periodontitis such as LFA-1 and Mac-1, are normal in LAgP patients.82,83
(GAgP) patients exhibit generalized interproximal attachment GAgP, often considered to be a disease of adolescents and
loss including at least three teeth that are not first molars and young adults, can begin at any age and often affects the entire
incisors. In young individuals, the onset of these diseases is dentition.84,85 Individuals with GAgP exhibit marked periodon-
often circumpubertal. Some investigators have found that the tal inflammation and have heavy accumulations of plaque and
localized form appears to be self-limiting,30 while others suggest calculus.84 In the United States, the reported prevalence of
that it is not.20 Some patients initially diagnosed as having GAgP in adolescents (14 to 17 years of age) is 0.13 percent.23
LAgP were found to have GAgP or to be periodontally healthy Subgingival sites from affected teeth harbor high percentages
at a 6-year follow-up exam.31,32 of non-motile, facultatively anaerobic, Gram-negative rods
LAgP occurs in children and adolescents without clinical including Porphyromonas gingivalis.86,87 In one report, the levels
evidence of systemic disease and is characterized by the severe of P. gingivalis and Treponema denticola were significantly
loss of alveolar bone around permanent teeth.31 Frequently, the higher in GAgP and LAgP patients compared to matched con-
disease is localized to the permanent first molars and incisors. trols, with GAgP patients having the highest levels.88 Neutro-
However, some retrospective data obtained from LAgP patients phils from patients with GAgP frequently exhibit suppressed
suggest that bone loss around the primary teeth can be an early chemotaxis as observed in LAgP77,87 with a concomitant
finding in the disease.33 Linkage studies of the Brandywine reduction in GP-110. This suggests a relationship between the
population (a segregated group of people in Maryland that two variants of aggressive periodontitis.82,83
represents a relatively closed gene pool) have found a gene Alterations in immunologic factors such as immuno-
conferring increased risk for LAgP on chromosome 4.34 globulins are known to be present in aggressive periodontitis.
Subsequent linkage studies of African American and Caucasian Immunoglobulins appear to be influenced by both genetic and
families did not confirm linkage to this locus, suggesting that environmental factors and have important protective disease-
there may be genetic and/or etiologic heterogeneity for aggres- limiting effects in aggressive periodontitis patients.89-93 Human
sive periodontitis.35-37 Reported estimates of the prevalence of IgG antibody molecules (immunoglobulin G) are categorized
LAgP in geographically diverse adolescent populations range into four subclasses designated as IgG1-4. Most of the anti-
from 0.1 to 15 percent.23,33-35,37-42 Most reports suggest a low body reactive with A. actinomycetemcomitans is specific for
prevalence (0.2 percent), which is markedly greater in African high molecular weight lipopolysaccharide and is of the IgG2
American populations (2.5 percent). subclass. This antibody response appears to be protective, as
Many reports suggest that patients with LAgP generally early-onset periodontitis patients having high concentrations
form very little supragingival dental plaque or calculus.31,43 of antibody reactive with A. actinomycetemcomitans
In contrast, other investigators find plaque and calculus at lipopolysaccharide have significantly less attachment loss (a
levels similar to other periodontal diseases.44,45 Bacteria of measure of disease severity) than patients who lack this
probable etiologic importance include highly virulent strains antibody.89,90
of Actinobacillus actinomycetemcomitans in combination with Overall levels of IgG2 in serum are under genetic control.91
Bacteroides-like species.46-49 In some populations, Eubacterium These levels have also been shown to be affected by periodontal
sp. have been associated with the presence of LAgP.50,51 To diagnosis (LAgP patients have very high levels), race (African
date, however, no single species is found in all cases of LAgP.52 Americans have higher levels than Caucasians), and smoking
A variety of functional defects have been reported in (smokers have lower levels of IgG2, with notable exceptions
neutrophils from patients with LAgP.53-55 These include anoma- in some patient groups).91,92,94,95 These factors also influence
lies of chemotaxis,56-58 phagocytosis,59,60 bactericidal activity,61 specific antibody responses to A. actinomycetemcomitans.91-93,95
superoxide production,62-66 FcgIIIB (CD16) expression,67 Thus, the protective antibody response afforded by IgG2, as
leukotriene B4 generation,68,69 and Ca2+–channel and second well as the clinical manifestations of aggressive periodontitis, is
messenger activation.70-75 The defect in chemotaxis is thought to modified by patients’ genetic background as well as environ-
be an intrinsic defect by some investigators56-58 and an induced mental factors such as smoking and bacterial infection.89,91-93,95,96
defect by others.76 The influence of these functional defects on


Successful treatment of aggressive periodontitis depends on ease can be mild (one to two millimeters clinical attachment
early diagnosis, directing therapy against the infecting micro- loss), moderate (three to four millimeters clinical attachment
organisms and providing an environment for healing that is loss), or severe (≥ five millimeters clinical attachment loss).
free of infection.97 While there is some disagreement among Children and young adults with this form of disease were
individual studies regarding treatment of LAgP, most authors previously studied along with patients having LAgP and GAgP.
recommend a combination of surgical or non-surgical root Therefore, published data are lacking for this group. In pa-
debridement in conjunction with antimicrobial (antibiotic) tients with one of several systemic diseases that predispose to
therapy.47,98 These findings are supported by other work in highly destructive disease of the primary teeth, the diagnosis
which meticulous and repeated mechanical therapy with anti- is periodontitis as a manifestation of systemic disease. As with
biotics proved to be sufficient to arrest most cases of LAgP.99 adults, periodontitis associated with systemic diseases occurs
However, surgical treatment may be effective in eliminating in children and adolescents. Such diseases include Papillon-
A. actinomycetemcomitans without the use of antibiotics.100 In Lefévre syndrome,121-125 cyclic neutropenia,126-130 agranulocy-
a study of 25 deep periodontal lesions (probing depths five tosis,131,132 Down syndrome,133-135 hypophosphatasia,136 and
to 11 millimeters) in young LAgP patients, scaling and root leukocyte adherence deficiency.137,138 It is probable that defects
planing alone were ineffective for the elimination of A. actino- in neutrophil and immune cell function associated with these
mycetemcomitans, while surgical therapy was effective.100 It is diseases play an important role in increased susceptibility to
not known, however, if A. actinomycetemcomitans is the only periodontitis and other infections. In Down syndrome, for
organism involved in disease pathogenesis. example, the amount of periodontal destruction has been
The majority of reports suggest that the use of antibio- shown to be positively correlated with the severity of the
tics is usually beneficial in the treatment of LAgP. Two reports neutrophil chemotaxis defect.135 In some cases, specific genes
described using antibiotics exclusively.97,101 In both reports, have been associated with these diseases. Examples include the
LAgP patients attained significant clinical attachment gain cathepsin C gene and Papillon-Lefévre syndrome139-141 and the
when assessed after 12 months with tetracycline therapy alone. tissue non-specific alkaline phosphatase gene and hypophos-
Most reports in the past 10 years, however, have recommend- phatasia.136
ed combination therapy using antibiotics and surgical or The consensus report of the 1999 Workshop specifically
non-surgical root debridement as the optimal treatment for excluded diabetes-associated periodontitis as a specific form
LAgP.98,102-116 The most successful antibiotics reported are the of periodontitis associated with systemic disease. Participants
tetracyclines, sometimes prescribed sequentially with metroni- concluded that diabetes is a significant modifier of all forms
dazole.103,117,118 Metronidazole in combination with amoxicillin of periodontitis. In a survey of 263 type 1 diabetics, 11 to 18
has also been utilized, especially where tetracyline-resistant years of age, 10 percent were found to have overt periodont-
A. actinomycetemcomitans are present.111 A single randomized itis often localized to first molars and incisors, although perio-
control study in which oral penicillin was used reported that dontitis was also found in a generalized pattern.142 Affected
therapy was successful with or without the antibiotic.119 subgingival sites harbored A. actinomycetemcomitans and
While the use of antibiotics in conjunction with surgical Capnocytophaga sp.143
or non-surgical root debridement appears to be quite effective Periodontitis as a manifestation of systemic disease in chil-
for the treatment of LAgP, GAgP does not always respond well dren is a rare disease that often begins between the time of
to conventional mechanical therapy or to antibiotics common- eruption of the primary teeth up to the age of four or five.144,145
ly used to treat periodontitis.30,118,120 Alternative antibiotics may The disease occurs in localized and generalized forms. In the
be required, based upon the character of the pathogenic flora. localized form, affected sites exhibit rapid bone loss and min-
In GAgP patients who have failed to respond to standard imal gingival inf lammation.144 In the generalized form, there
periodontal therapy, laboratory tests of plaque samples may is rapid bone loss around nearly all teeth and marked gingival
identify periodontal pathogens that are resistant to antibiotics inflammation. Neutrophils from some children with a clini-
typically used to treat periodontitis.103 It has been suggested cal diagnosis of periodontitis as a manifestation of systemic
that follow-up tests after additional antibiotic or other therapy disease have abnormalities in a cell surface glycoprotein (LFA-1,
is provided may be helpful in confirming elimination of tar- leukocyte functional antigen–1, also known as CD11, and
geted pathogenic organisms.103 Mac-1). The neutrophils in these patients having LAD
Chronic periodontitis is most prevalent in adults, but can (leukocyte adhesion deficiency) are likely to have a decreased
occur in children and adolescents. It can be localized (less than ability to move from the circulation to sites of inflammation
30 percent of the dentition affected) or generalized (greater and infection.137 Affected sites harbor elevated percentages of
than 30 percent of the dentition affected) and is characterized putative periodontal pathogens such as A. actinomycetem-
by a slow to moderate rate of progression that may include comitans, Prevotella intermedia, Eikenella corrodens, and
periods of rapid destruction. Furthermore, the severity of dis- Capnocytophaga sputigena.146,147


Treatment of periodontitis as a manifestation of systemic Acknowlegments

disease in children is similar to the treatment of localized and The primary author for this paper is Dr. Joseph V. Califano.
generalized aggressive periodontitis in the permanent denti- Members of the 2002-2003 Research, Science and Therapy
tion and has been reported to include surgical or non-surgical Committee include: Drs. Terry D. Rees, Chair; Christopher
mechanical debridement and antimicrobial therapy.124,127-130,132, Cutler; Petros Damoulis; Joseph Fiorellini; William Giannobile;
134,142,144
Localized lesions have been treated successfully with Henry Greenwell; Angelo Mariotti; Steven Offenbacher;
this approach,144,145 but the degree of predictable success in Leslie Salkin; Brian Nicoll, Board Liaison; Robert J. Genco,
managing generalized periodontitis is low when systemic Consultant.
diseases are contributing factors.144,145 In many cases, the
affected teeth had to be extracted.138,144,145 References
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134. Orner G. Periodontal disease among children with Down 149. Smith BW, Dennison DK, Newland JR. Acquired HIV
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135. Izumi Y, Sugiyama S, Shinozuki O, Yamazaki T, Ohyama dentist. Va Dent J 1987;63:38-42.
T, Ishikawa I. Defective neutrophil chemotaxis in Down 150. Contreras A, Falkler WA Jr., Enwonwu CO, et al. Human
syndrome patients and its relationship to periodontal de- Herpes viridae in acute necrotizing ulcerative gingivitis
struction. J Periodontol 1989;60:238-42. in children in Nigeria. Oral Microbiol Immunol 1997;
136. Watanabe H, Goseki-Sone M, Iimura T, Oida S, Orimo 12:259-65.
H, Ishikawa I. Molecular diagnosis of hypophosphatasia 151. Loesche WJ, Syed SA, Laughon BE, Stoll J. The bacteriol-
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functional abnormality in neutrophils from patients with 152. Listgarten M. Electron microscopic observations on the
generalized prepubertal periodontitis. J Periodont Res bacterial flora of acute necrotizing ulcerative gingivitis.
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cathepsin C gene are responsible for Papillon-Lefévre 1357-71.
syndrome. J Med Genet 1999;36:881-7. 155. Jimenez LM, Baer PN. Necrotizing ulcerative gingivitis
140. Hart TC, Hart PS, Michalec MD, et al. Localization of a in children: A 9-year clinical study. J Periodontol 1975;
gene for prepubertal periodontitis to chromosome 11q14 46:715-20.
and identification of a cathepsin C gene mutation. J Med 156. Pindborg JJ, Bhat M, Devanath KR, Narayana HR,
Genet 2000;37:95-101. Ramachandra S. Occurrence of acute necrotizing gingivitis
141. Hart TC, Shapira L. Papillon-Lefévre syndrome. Perio- in South Indian children. J Periodontol 1966;37:14-9.
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Prevalence of periodontal disease in insulin-dependent 158. Johnson B, Engel D. Acute necrotizing ulcerative gin-
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143. Mashimo PA, Yamamoto Y, Slots J, Park BH, Genco RJ.
The periodontal microflora of juvenile diabetics. Culture,
immunofluorescence, and serum antibody studies. J Individual copies of this paper may be obtained on the
Periodontol 1983;54:420-30. Academy’s website at: “http://www.perio.org”. Members of the
144. Page RC, Bowen T, Altman L, et al. Prepubertal perio- American Academy of Periodontology have permission of the
dontitis. I. Definition of a clinical entity. J Periodontol Academy, as copyright holder, to reproduce up to 150 copies
1983;54:257-71. of this document for not-for-profit, educational purposes only.
145. Watanabe K. Prepubertal periodontitis: A review of diag- For information on reproduction of the document for any
nostic criteria, pathogenesis, and differential diagnosis. J other use or distribution, please contact Rita Shafer at the
Periodont Res 1990;25:31-48. Academy Central Office; voice: (312) 573-3221; fax: (312)
146. Sweeney EA, Alcoforado GAP, Nyman S, Slots J. Preval- 573-3225; or e-mail: rita@perio.org.
ence and microbiology of localized prepubertal perio-
dontitis. Oral Microbiol Immunol 1987;2:65-70.
147. Delaney DE, Kornman KS. Microbiology of subgingival
plaque from children with localized prepubertal perio-
dontitis. Oral Microbiol Immunol 1987;2:71-6.


ENDORSEMENTS: PERIODONTAL THERAPY
Guidelines for Periodontal Therapy

How to Cite: American Academy of Periodontology. Guidelines for
periodontal therapy. J Periodontol 2001;72:1624-1628.
2003
Originating Group
American Academy of Periodontology
Abstract
The American Academy of Periodontology offers the following Guidelines for Periodontal Therapy. These guidelines are intended to fulfill
the Academy’s obligation to the public and to the dental profession. This paper sets forth the clinical objectives and scope of periodontal
therapy. These guidelines are designed to give guidance to state legislatures and agencies that regulate the practice of periodontology
and should be considered in their entirety. J Periodontol 2001;72:1624-1628.
Research has provided evidence that chronic inflammatory as tooth replacements are, when indicated, integral components
periodontal diseases are treatable.1-8 Studies have also been of comprehensive periodontal therapy. Tooth extraction and
directed at providing information to permit better understand- implant site development may accompany either periodontal
ing of mechanisms of disease progression and pathogenesis in or implant therapy. Patient management during therapy may
order to make treatment of periodontal diseases more effective include the administration of intravenous conscious sedation.
and predictable.9-11 As a result of advances in knowledge and The goals of periodontal therapy are to preserve the
therapy, the great majority of patients retain their dentition over natural dentition, periodontium and peri-implant tissues; to
their lifetime with proper treatment, reasonable plaque control, maintain and improve periodontal and peri-implant health,
and continuing maintenance care.12-21 However, there are some comfort, esthetics, and function. Currently accepted clinical
situations when traditional therapy is not effective in arresting signs of a healthy periodontium include the absence of in-
the disease. In these instances, the progression of the disease flammatory signs of disease such as redness, swelling, suppura-
may be slowed, but eventually the teeth may be lost.14-21 tion, and bleeding on probing; maintenance of a functional
Adherence to the following guidelines will not guarantee periodontal attachment level; minimal or no recession in the
a successful outcome and will not obviate all complications or absence of interproximal bone loss; and functional dental
postcare problems in periodontal therapy. Additionally, these implants.
guidelines should not be deemed inclusive of all methods of
care, or exclusive of treatment reasonably directed at obtaining Periodontal examination
the same results. It should also be noted that these guidelines All patients should receive a comprehensive periodontal
describe summaries of patient evaluation and treatment proce- examination. Such an examination includes discussion with
dures that have been presented in considerably more detail the patient regarding the chief complaint, medical and dental
within textbooks of periodontology as well as in the medical history review, clinical examination, and radiographic analysis.
and dental literature. Ultimately judgments regarding the Microbiologic, genetic, biochemical, or other diagnostic tests
appropriateness of any specific procedure must be made by may also be useful, on an individual basis, for assessing the
the practitioner in light of all the circumstances presented by periodontal status of selected patients or sites. Some or all of
the individual patient. the following procedures may be included in a comprehen-
sive periodontal examination:
Scope of periodontics 1. Extra- and intraoral examination to detect non-
Periodontics is the specialty of dentistry that encompasses periodontal oral diseases or conditions.
prevention, diagnosis, and treatment of diseases of the sup- 2. General periodontal examination to evaluate the topo-
porting and surrounding tissues of teeth and dental implants. pography of the gingiva and related structures; to
The specialty includes maintenance of the health, function, assess probing depth, recession, and attachment level;
and esthetics of all supporting structures and tissues (gingiva, to evaluate the health of the subgingival area with
periodontal ligament, cementum, alveolar bone, and sites for measures such as bleeding on probing and suppura-
tooth replacements). Tissue regeneration, management of tion; to assess clinical furcation status; and to detect
periodontal-endodontic lesions, and providing dental implants endodontic-periodontal lesions.

© 2001 American Academy of Periodontology. J Periodontol 2001;72(11):1624-1628. Available at: “https://doi.org/10.1902/jop.2001.72.11.1624”.
The Journal of Periodontology is published for the American Academy of Periodontology by John Wiley and Sons.

3. Assessment of the presence, degree and/or distribu- Development of a treatment plan

tion of plaque, calculus and gingival inflammation. The clinical findings together with a diagnosis and prognosis
4. Dental examination, including caries assessment, should be used to develop a logical plan of treatment in order
proximal contact relationships, the status of dental to eliminate or alleviate the signs and symptoms of periodontal
restorations and prosthetic appliances, and other diseases and thereby arrest or slow further disease progression.
tooth- or implant-related problems. The treatment plan should be used to establish the methods
5. Determination of the degree of mobility of teeth and and sequence of delivering appropriate periodontal treatment.
dental implants. When indicated, the plan should include:
6. Occlusal examination. 1. Medical consultation or referral for treatment when
7. Interpretation of a satisfactory number of updated, di- appropriate.
agnostic quality periapical and bite-wing radiographs or 2. Periodontal procedures to be performed.
other diagnostic imaging needed for implant therapy. 3. Consideration of adjunctive restorative, prosthetic,
8. Evaluation of potential periodontal systemic inter- orthodontic and/or endodontic consultation or
relationships. treatment.
9. Assessment of suitability to receive dental implants. 4. Provision for re-evaluation during and after perio-
dontal or dental implant therapy.
Establishing a diagnosis and prognosis 5. Consideration of chemotherapeutic agents for ad-
The purpose of the comprehensive periodontal examination junctive treatment.
is to determine the periodontal diagnosis and prognosis and/ 6. Consideration of diagnostic testing that may include
or suitability for dental implants. This process includes an microbiological, genetic or biochemical assessment or
evaluation of periodontal and peri-implant tissues to determine monitoring during the course of periodontal therapy.
the suitability of the patient for treatments including non- 7. Periodontal maintenance program.
surgical, surgical, regenerative and reconstructive therapy, or
dental implant placement. This information should be record- Informed consent and patient records
ed in the patient’s chart and communicated to the patient and Where reasonably foreseeable risks, potential complications, or
the referring dentist when appropriate. the possibility of failure are associated with treatment, informed
consent should be obtained prior to the commencement of
Periodontal diseases and conditions therapy. The information given to the patient in these circum-
Diseases of the periodontium may be categorized as gingival stances should include the following:
diseases, periodontitis, necrotizing periodontal diseases, abs- 1. The diagnosis, etiology, proposed therapy, possible
cesses of the periodontium, and developmental or acquired alternative treatment(s), and the prognosis with and
deformities and conditions.22 Gingivitis is gingival inflam- without the proposed therapy or possible alternatives.
mation without attachment loss or with non-progressing 2. Recommendations for referral to other health care
attachment loss. Other gingival diseases may be modified by providers as necessary.
systemic factors, medications or malnutrition. Periodontitis 3. The reasonably foreseeable inherent risks and potential
is gingival inflammation with progressing attachment loss. complications associated with the proposed therapy,
Different forms include, but are not limited to, chronic including failure with the ultimate loss of teeth or
periodontitis, aggressive periodontitis, periodontitis as a dental implants.
manifestation of systemic disease, necrotizing ulcerative 4. The need for periodontal maintenance treatment
periodontitis, and periodontitis associated with endodontic after active therapy due to the potential for disease
lesions. Periodontitis may be further characterized by degree recurrence.
of attachment loss as slight, moderate, or severe; by extent
as localized or generalized; and by post-treatment status A record of the patient’s consent to the proposed therapy
as recurrent or refractory. Facial recession involving loss of should be maintained. Moreover, complete records of diagnosis,
periodontal attachment and gingival tissue affects children and treatment, results, and recommended follow-up are essential,
adults. The prevalence increases with age and adults over 50 starting with the initial examination and continuing for as long
have the greatest degree of involvement. This mucogingival as the patient is under care. Where reasonably foreseeable risks,
condition is often treatable.23 Edentulous ridge defects result potential complications, or the possibility of failure are associ-
from loss of osseous tissue and can compromise esthetics or ated with treatment, it is advisable to obtain the informed
complicate future implant placement. Other diseases and consent in writing prior to commencement of therapy.
anomalies not explicitly described herein may also involve the
periodontium.


Treatment procedures 6. Preprosthetic periodontal procedures include: explora-

A broad range of therapies exist in periodontics. No single tory flap surgery, resective procedures, regenerative or
treatment approach can provide the only means of treating any reconstructive procedures, or crown lengthening sur-
one or all periodontal diseases. One treatment modality may gery, performed to facilitate restorative or prosthetic
be appropriate for one section of the mouth while another treatment plans.
approach may be suitable at other sites. 7. Selective extraction of teeth, roots, or implants when
When indicated, treatment should include: indicated, in order to facilitate periodontal therapy,
1. Patient education, training in personal oral hygiene, implant therapy, implant site development, or im-
and counseling on control of risk factors (e.g., smo- plant, restorative and/or prosthetic treatment plans.
king, medical status, stress) with referral when 8. Replacement of teeth by dental implants.
appropriate. 9. Procedures to facilitate orthodontic treatment includ-
2. Removal of supragingival and accessible subgingival ing, but not limited to, tooth exposure, frenulectomy,
bacterial plaque and calculus is accomplished by fiberotomy, gingival augmentation, and implant
periodontal scaling. Comprehensive periodontal root placement.
planing is used to treat root surface irregularities or 10. Management of periodontal systemic interrelation-
alterations caused by periodontal pathoses. In some ships when appropriate.
instances, these procedures may be incorporated into
the surgical treatment. Periodontal maintenance therapy
3. Finishing procedures, which include post-treatment Upon completion of active periodontal treatment, follow-up
evaluation with review and reinforcement of personal periodontal maintenance visits should include:
daily oral hygiene when appropriate. 1. Update of medical and dental histories.
2. Evaluation of current extra- and intraoral, periodontal
The following courses of treatment may be indicated in and peri-implant soft tissues as well as dental hard
addition to the above outlined procedures: tissues and referral when indicated (e.g., for treat-
1. Chemotherapeutic agents. These agents may be used ment of carious lesions, pulpal pathosis, or other
to reduce, eliminate, or change the quality of micro- conditions).
bial pathogens; or alter the host response through 3. Assessment of the oral hygiene status with reinstruc-
local or systemic delivery of appropriate agent(s). tion when indicated.
2. Resective procedures. These procedures are designed to 4. Mechanical toothcleaning to disrupt/remove dental
reduce or eliminate periodontal pockets and create plaque and biofilms, stain, and calculus. Local deliv-
an acceptable gingival form that will facilitate effective ery or systemic chemotherapeutic agents may be used
oral hygiene and periodontal maintenance treatment. as adjunctive treatment for recurrent or refractory
Soft tissue procedures include gingivectomy, gin- disease.
givoplasty, and various mucogingival flap procedures. 5. Elimination or mitigation of new or persistent risk
Osseous procedures include ostectomy and osteo and etiologic factors with appropriate treatment.
plasty. Dental tissue procedures include root resection, 6. Identification and treatment of new, recurrent, or re-
tooth hemisection, and odontoplasty. Combined fractory areas of periodontal pathoses.
osseous and dental tissue procedures may be required 7. Establishment of an appropriate, individualized inter
for management of endodontic-periodontal lesions. val for periodontal maintenance treatment.
3. Periodontal regenerative procedures include: soft tissue The patient should be kept informed of:
grafts, bone replacement grafts, root biomodification, 1. Areas of persistent, recurrent, refractory, or new
guided tissue regeneration, and combinations of these periodontal disease.
procedures for osseous, furcation, and recession de- 2. Changes in the periodontal prognosis.
fects. Periodontal reconstructive procedures include: 3. Advisability of further periodontal treatment or re-
guided bone regeneration, ridge augmentation, ridge treatment of indicated sites.
preservation, implant site development, and sinus 4. Status of dental implants.
grafting. 5. Other oral health problems noted that may include
4. Periodontal plastic surgery for gingival augmentation, caries, defective restorations, and non-periodontal
for correction of recession or soft tissue defects, or mucosal diseases or conditions.
for other enhancement of oral esthetics.
5. Occlusal therapy, which may include: minor tooth Factors modifying results
movement, occlusal adjustment, splinting, or provi- The results of periodontal treatment may be adversely affected
sion of devices to reduce occlusal trauma. by circumstances beyond the control of the dentist.10 Examples


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17. Goldman M, Ross I, Goteiner D. Effect of periodontal 29. Machtei E, Zubrey Y, Yehuda B, Soskolne A. Proximal
therapy on patients maintained for 15 years or longer. bone loss adjacent to periodontally hopeless teeth with
J Periodontol 1986;57:347-53. and without extraction. J Periodontol 1989;60:512-5.
18. Oliver R. Tooth loss with and without periodontal 30. Rose LF, Steinberg BJ, Atlas SL. Periodontal management
therapy. J West Soc Periodontol 1969;17:8-9. of the medically compromised patient. Periodontol 2000
19. Wilson T, Glover M, Malik A, Schoen J, Dorsett D. 1995;9:165-75.
Tooth loss in maintenance patients in a private perio-
dontal practice. J Periodontol 1987;58:231-5. Acknowledgments
20. Nabers C, Stalker W, Esparza D, Naylor B, Canales S. Tooth The primary author for the revision of this position paper is
loss in 1535 treated periodontal patients. J Periodontol Dr. Henry Greenwell. It replaces the paper titled Guidelines
1988;59:297-300. for Periodontal Therapy which had been revised by Dr. Robert
21. Chace R, Low S. Survival characteristics of periodon- E. Cohen and approved by the Board of Trustees in December
tally involved teeth: A 40-year study. J Periodontol 1993; 1997. Members of the 2000-2001 Research, Science and Ther-
64:701-5. apy Committee include: Drs. David Cochran, Chair; Timothy
22. Armitage GC. Development of a classification system Blieden; Otis J. Bouwsma; Robert E. Cohen; Petros Damoulis;
for periodontal diseases and conditions. Ann Periodontol Connie H. Drisko; Joseph P. Fiorellini; Gary Greenstein;
1999;4:1-6. Vincent J. Iacono; Martha J. Somerman; Terry D. Rees; Angelo
23. Albandar JM, Kingman A. Gingival recession, gingival Mariotti, Consultant; Robert J. Genco, Consultant; and Brian
bleeding and dental calculus in adults 30 years of age L. Mealey, Board Liaison.
and older in the United States, 1988-1994. J Periodontol
1999;70:30-43.
24. Mealey B. Diabetes and periodontal diseases (position Individual copies of this position paper may be obtained
paper). J Periodontol 2000;71:664-78. by accessing the Academy’s website at: “http://www.perio.org”.
25. Axelsson P, Lindhe J. The significance of maintenance Members of the American Academy of Periodontology have
care in the treatment of periodontal disease. J Clin permission of the Academy, as copyright holder, to reproduce
Periodontol 1981;8:281-94. up to 150 copies of this document for not-for-profit, educa-
26. Lindhe J, Westfelt E, Nyman S, Socransky S, Haffajee tional purposes only. For information on reproduction of the
A. Long-term effect of surgical/non-surgical treatment of document for any other use or distribution, please contact Rita
periodontal disease. J Clin Periodontol 1984;11:448-58. Shafer at the Academy Central Office; voice: (312) 573-3221;
27. Johnson GK. Tobacco use and the periodontal patient fax: (312) 573-3225; or e-mail: rita@ perio.org.
(position paper). J Periodontol 1999;70:1419-27.
28. Pennel B, Keagle J. Predisposing factors in the etiology
of chronic inflammatory periodontal disease. J Perio-
dontol 1977;48:517-32.


ENDORSEMENTS: TREATMENT OF CLINICAL CONDITIONS
Treatment of Plaque-induced Gingivitis, Chronic

Periodontitis, and Other Clinical Conditions
How to Cite: Research, Science and Therapy Committee Guidelines
of the American Academy of Periodontology. Treatment of plaque-
2004 induced gingivitis, chronic periodontitis, and other clinical conditions.
J Periodontol 2001;72:1790-1800.
Originating Group
American Academy of Periodontology – Research, Science
and Therapy Committee
Abstract
This paper has been prepared by the Research, Science and Therapy Committee of the American Academy of Periodontology and is intended
for the information of the dental profession. It represents the position of the Academy regarding the current state of knowledge about
treatment of plaque-induced gingivitis, chronic periodontitis, and some other clinical conditions. Two other papers entitled The Pathogenesis
of Periodontal Diseases and Diagnosis of Periodontal Diseases also reflect the Academy’s position on these subjects. J Periodontol 2001;72:
1790-1800.
Gingivitis and periodontitis are the two major forms of in- other factors can contribute to periodontal disease pathogenesis:
flammatory diseases affecting the periodontium. Their primary environmental, genetic, and systemic (e.g., diabetes).14,15
etiology is bacterial plaque, which can initiate destruction of This paper primarily reviews the treatment of plaque-
the gingival tissues and periodontal attachment apparatus.1,2 induced gingivitis and chronic periodontitis, but there might
Gingivitis is inflammation of the gingiva that does not result be some situations where the described therapies will not
in clinical attachment loss. Periodontitis is inflammation of the resolve disease or arrest disease progression. Furthermore, the
gingiva and the adjacent attachment apparatus and is character- treatments discussed should not be deemed inclusive of all
ized by loss of connective tissue attachment and alveolar bone. possible therapies, or exclusive of methods of care reasonably
Each of these diseases may be subclassified based upon etiol- directed at obtaining good results. The ultimate decision re-
ogy, clinical presentation, or associated complicating factors.3 garding the appropriateness of any specific procedure must
Gingivitis is a reversible disease. Therapy is aimed primarily be made by the practitioner in light of the circumstances
at reduction of etiologic factors to reduce or eliminate inflam- presented by an individual patient.
mation, thereby allowing gingival tissues to heal. Appropriate
supportive periodontal maintenance that includes personal and Plaque-induced gingivitis
professional care is important in preventing re-initiation of Therapy for individuals with chronic gingivitis is initially
inflammation. directed at reduction of oral bacteria and associated calcified
Therapeutic approaches for periodontitis fall into two major and noncalcified deposits. Patients with chronic gingivitis, but
categories: 1) anti-infective treatment, which is designed to halt without significant calculus, alterations in gingival morphology,
the progression of periodontal attachment loss by removing or systemic diseases that affect oral health, may respond to a
etiologic factors; and 2) regenerative therapy, which includes therapeutic regimen consisting of improved personal plaque
anti-infective treatment and is intended to restore structures control alone.16 The periodontal literature documents the short-
destroyed by disease. Essential to both treatment approaches and long-term effects following self-treatment of gingivitis by
is the inclusion of periodontal maintenance procedures.4 personal plaque control.16-20 However, while it may be possible
Inflammation of the periodontium may result from many under controlled conditions to remove most plaque with a
causes (e.g., bacteria, trauma). However, most forms of gingivitis variety of mechanical oral hygiene aids, many patients lack the
and periodontitis result from the accumulation of tooth- motivation or skill to attain and maintain a plaque-free state
adherent microorganisms.5-7 Prominent risk factors for devel- for significant periods of time.21-23 Clinical trials also indicate
opment of chronic periodontitis include the presence of that self-administered plaque control programs alone, without
specific subgingival bacteria,8-10 tobacco use,9-13 diabetes,9,10,14 periodic professional reinforcement, are inconsistent in provi-
age,9,10 and male gender.9,10 Furthermore, there is evidence that ding long-term inhibition of gingivitis.19,24,25


Many patients with gingivitis have calculus or other associa-ted reduction of oral bacteria by a combination of personal plaque
local factors (e.g., defective dental restorations) that interfere control and professional debridement. If lymphadenopathy or
with personal oral hygiene and the ability to remove bacterial fever accompanies oral symptoms, administration of systemic
plaque. An acceptable therapeutic result for these individuals antibiotics may be indicated. The use of chemotherapeutic
is usually obtained when personal plaque control measures rinses by the patient may be beneficial during the initial
are performed in conjunction with professional removal of treatment stages. After the acute inflammation of the NUG
plaque, calculus, and other local contributing factors.26,27 lesion is resolved, additional intervention may be indicated
Removal of dental calculus is accomplished by scaling and to prevent disease recurrence or to correct resultant soft tissue
root planing procedures using hand, sonic, or ultrasonic deformities.
instruments. The therapeutic objective of scaling and root Necrotizing ulcerative periodontitis (NUP) manifests as
planing is to remove plaque and calculus to reduce subgingival rapid necrosis and destruction of the gingiva and periodontal
bacteria below a threshold level capable of initiating clinical attachment apparatus. It may initiate gingival bleeding and pain,
inflammation. The success of instrumentation is determined and it usually represents an extension of necrotizing ulcerative
by evaluating the periodontal tissues following treatment and gingivitis in individuals with lowered host resistance. NUP has
during the maintenance phase of therapy. been reported among both HIV-positive and negative indi-
The use of topical antibacterial agents to help reduce viduals, but its true prevalence is unknown.33-38 Management
bacterial plaque may be beneficial for the prevention and treat- of NUP involves debridement which may be combined with
ment of gingivitis in some patients.28-30 irrigation with antiseptics (e.g., povidone iodine), antimicrobial
A number of these agents in oral rinses and dentifrices mouth rinses (e.g., chlorhexidine), and administration of sys-
have been tested in clinical trials.28 However, to be accepted by temic antibiotics.39 There is also evidence that HIV-immune
the American Dental Association (ADA) Council on Dental deficiency may be associated with severe loss of periodontal
Therapeutics as an effective agent for the treatment of gingivitis, attachment that does not necessarily present clinically as an
a product must reduce plaque and demonstrate effective reduc- ulcerative lesion.40 Although not an acute disease, linear gin-
tion of gingival inflammation over a period of at least 6 months. gival erythema (LGE) occurs in some HIV-infected individuals
The agent must also be safe and not induce adverse side effects. and does not appear to respond to conventional scaling, root
Three medicaments have been given the ADA Seal of planing, and plaque control.39 Antibiotic therapy should be
Acceptance for the control of gingivitis. The active ingredients used in HIV-positive patients with caution due to the pos-
of one product are thymol, menthol, eucalyptol, and methyl sibility of inducing opportunistic infections.39,40
salicylate.29 Active ingredients in the other two are chlorhexi- The oral manifestations of a primary herpes simplex virus
dine digluconate and triclosan.29 If properly used, the addition type I infection often include gingivitis. By the time gingivitis
of a topical anti-plaque agent to a gingivitis treatment regimen is present, patients are usually febrile, in pain, and have
for patients with deficient plaque control will likely result lymphadenopathy. Diagnosis is generally made from the clini-
in reduction of gingivitis.30 However, experimental evidence cal appearance of the oral soft tissues. Although not performed
indicates that penetration of topically applied agents into the routinely, a viral culture may provide definitive identification
gingival crevice is minimal.31 Therefore, these agents are useful of the infective agent. In otherwise healthy patients, treatment
for the control of supragingival, but not subgingival plaque. for herpetic gingivitis consists of palliative therapy. The infec-
Among individuals who do not perform excellent oral hy- tion is self-limiting and usually resolves in seven to 10 days.
giene, supragingival irrigation with and without medicaments Systemic antiviral therapy with acyclovir is appropriate for
is capable of reducing gingival inflammation beyond that immuno-compromised patients with herpetic gingivitis.41
normally achieved by toothbrushing alone. This effect is likely
due to the flushing out of subgingival bacteria.32 Gingival enlargement
If gingivitis remains following the removal of plaque and Chronic gingival inflammation may result in gingival enlarge-
other contributing local factors, thorough evaluation should be ment. This overgrowth of gingiva may be exaggerated in patients
undertaken of systemic factors (e.g., diabetes, pregnancy, etc.) with genetic or drug-related systemic factors (e.g., anticonvul-
If such conditions are present, gingival health may be attained sants, cyclosporine and calcium channel blocking drugs).42-46
once the systemic problem is resolved and plaque control is Among individuals taking phenytoin, gingival overgrowth
maintained. may be minimized with appropriate personal oral hygiene and
professional maintenance.47,48 However, root debridement in
Acute periodontal diseases patients with gingival overgrowth often does not return the
Necrotizing ulcerative gingivitis (NUG) is associated with periodontium to normal contour. The residual overgrowth may
specific bacterial accumulations occurring in individuals with not only complicate the patient’s ability to adequately clean
lowered host resistance.1 NUG usually responds rapidly to the the dentition, but it may also present esthetic and functional
problems.49


For patients with gingival overgrowth, the modification control is not adequate to maintain gingival health, then
of tissue topography by surgical recontouring may be under- additional instruction and motivation in personal plaque
taken to create a maintainable oral environment.47,50 Postoper- control and/or the use of topical chemotherapeutics (e.g.,
ative management following tissue resection is important. mouthrinses, local drug delivery devices) may be indicated.
The benefits of surgical reduction may be lost due to rapid Anatomical factors that can limit the effectiveness of root
proliferation of the tissues during the post-therapy phase.51 instrumentation or limit the patient’s ability to perform per-
Recurrence is common in many patients with drug-induced sonal plaque control (e.g., deep probing depths, root concavities,
gingival overgrowth.51 For these patients, consultation with the furcations) may require additional therapy including surgery.
patient’s physician is advisable to determine if it is possible to Host response may also have an effect on treatment outcome
use an alternative drug therapy that does not induce gingival and patients with systemic conditions (e.g., diabetes, preg-
overgrowth. If not, then repeated surgical and/or non-surgical nancy, stress, AIDS, immunodeficiencies, and blood dyscrasias)
intervention may be required. may not respond well to therapy that is directed solely at
controlling local factors. In such patients, it is important that
Chronic periodontitis attempts be made to control the contributing systemic factors.
Appropriate therapy for patients with periodontitis varies
considerably with the extent and pattern of attachment loss, Pharmacological therapy
local anatomical variations, type of periodontal disease, and Pharmacotherapeutics may have an adjunctive role in the
therapeutic objectives. Periodontitis destroys the attachment management of periodontitis in certain patients.73 These ad-
apparatus of teeth resulting in periodontal pocket formation junctive therapies are categorized by their route of adminis-
and alteration of normal osseous anatomy. The primary ob- tration to diseased sites: systemic or local drug delivery.
jectives of therapy for patients with chronic periodontitis
are to halt disease progression and to resolve inflammation. Systemic drug administration
Therapy at a diseased site is aimed at reducing etiologic factors Numerous investigations73 have assessed the use of systemic
below the threshold capable of producing breakdown, thereby antibiotics to halt or slow the progression of periodontitis or to
allowing repair of the affected region. Regeneration of lost improve periodontal status. The adjunctive use of systemically
periodontal structures can be enhanced by specific procedures. delivered antibiotics may be indicated in the following situa-
However, many variables responsible for complete regeneration tions: patients with multiple sites unresponsive to mechanical
of the periodontium are unknown and research is ongoing in debridement, acute infections, medically compromised patients,
this area. presence of tissue-invasive organisms and ongoing disease
progression.74-77 The administration of antibiotics for the
Scaling and root planing treatment of chronic periodontitis should follow accepted
The beneficial effects of scaling and root planing combined pharmacological principles including, when appropriate, iden-
with personal plaque control in the treatment of chronic peri- tification of pathogenic organisms and antibiotic sensitivity
odontitis have been validated.52-65 These include reduction testing.
of clinical inflammation, microbial shifts to a less pathogenic Considerable research efforts have focused on systemic
subgingival flora, decreased probing depth, gain of clinical application of host modulating agents such as non-steroidal
attachment, and less disease progression.52-65 anti-inflammatory drugs (NSAIDS)78-80 and subantimicrobial
Scaling and root planing procedures are technically de- dose doxycycline.81-84 Investigators have reported some benefit
manding and time-consuming. Studies show that clinical when these medications are incorporated into treatment proto-
conditions generally improve following root planing; nonethe- cols.78,81-84 Recently [year 2000], the United States Food and
less, some sites still do not respond to this therapy.62,63,66,67 The Drug Administration (FDA) approved the use of a systemically
addition of gingival curettage to root planing in the treatment delivered collagenase inhibitor consisting of a 20-mg capsule of
of generalized chronic periodontitis with shallow suprabony doxycycline hyclate as an adjunct to scaling and root planing
pockets does not significantly reduce probing depth or gain for the treatment of periodontitis. Benefits included a statisti-
clinical attachment beyond that attained by scaling and root cally significant reduction in probing depths, a gain in clinical
planing alone.68,69 The following factors may limit the success attachment levels and a reduction in the incidence of disease
of treatment by root planing: root anatomy (e.g., concavities, progression.82-84 Overall, the data suggest that use of subantimi-
furrows etc.), furcations,66 and deep probing depths.70-72 crobial dose doxycycline as an adjunct to scaling and root planing
Several weeks following the completion of root planing provides defined but limited improvement in periodontal status.
and efforts to improve personal plaque control, re-evaluation It is important to consider the potential benefits and
should be conducted to determine the treatment response. side effects of systemic pharmacological therapy. Benefits may
Several factors must be considered at sites that continue to include the ability to treat patients unresponsive to conventional
exhibit signs of disease. If the patient’s daily personal plaque therapy or an individual with multiple sites experiencing


recurrent periodonitits. In contrast, potential risks associated the American Academy of Periodontology position paper “The
with systemically administered antibiotics include development Role of Controlled Drug Delivery for Periodontitis”.87
of resistant bacterial strains,85 emergence of opportunistic in-
fections, and possible allergic sensitization of patients.73 With Surgical therapy
regard to the prolonged administration of NSAIDS, harmful Surgical access to facilitate mechanical instrumentation of the
effects may include gastrointestinal upset and hemorrhage, roots has been utilized to treat chronic periodontitis for dec-
renal and hepatic impairment, central nervous system ades. A surgical approach to the treatment of periodontitis is
disturbances, inhibition of platelet aggregation, prolonged utilized in an attempt to: 1) provide better access for removal
bleeding time, bone marrow damage, and hypersensitivity of etiologic factors; 2) reduce deep probing depths; and 3)
reactions.73 At present, the incidence of negative side effects regenerate or reconstruct lost periodontal tissues.96-98
reported after root planing with or without administration Clinical trials indicate that both surgical and nonsurgical
of subantimicrobial dose doxy-cycline has been similar. In approaches can be effective in achieving stability of clinical
general, since patients with chronic periodontitis respond to attachment levels.60-65,99-103 Flap reflection is capable, however,
conventional therapy, it is unnecessary to routinely admin- of increasing the efficacy of root debridement, especially at
ister systemic medications such as antibiotics, NSAIDS, or sites with deep probing depths or furcations.60-65,70,72,99-104
subantimicrobial dosing with doxycycline. Nevertheless, complete calculus removal, even with surgi-
cal access, may not always be achieved.70,72,104 The addition of
Local delivery osseous resection during surgical procedures appears to produce
Controlled delivery of chemotherapeutic agents within peri- greater reduction of probing depth due to gingival reces-
odontal pockets can alter the pathogenic flora and improve sion,62,64,65 particularly in furcations.66 Regardless of the type of
clinical signs of periodontitis.86-94 Local drug delivery systems therapy, furcated teeth are problematic since they are still more
provide several benefits; the drug can be delivered to the site likely to lose clinical attachment than nonfurcated teeth.66,67,105
of disease activity at a bactericidal concentration and it can While these overall findings are helpful, the practitioner
facilitate prolonged drug delivery. The FDA has approved the should base specific decisions for therapy on findings for each
use of an ethylene vinyl acetate fiber that contains tetracy- individual patient.
cline,86-91 a gelatin chip that contains chlorhexidine93 and a
minocycline polymer formulation92 as adjuncts to scaling and Regenerative surgical therapy
root planing. The FDA has also approved doxycycline hyclate The optimal goal of therapy for individuals who have lost a
in a bioabsorbable polymer gel as a stand-alone therapy for the significant amount of periodontal attachment is regeneration
reduction of probing depths, bleeding upon probing, and gain of lost tissues. While root debridement in combination with
of clinical attachment.94 plaque control has demonstrated efficacy in resolving inflam-
Local delivery systems have potential limitations and mation and arresting periodontitis,26,27,60-65 healing typically
benefits. If used as a monotherapy, problems associated with results in the formation of a long junctional epithelium106-108
local delivery can include allergic reaction, possible inability to with remodeling of the alveolus.109 Similarly, surgical debride-
disrupt biofilms, and failure to remove calculus.95 The benefits ment alone does not induce significant amounts of new
include the ease of application, selectively targeting a limited connective tissue attachment.110,111 However, some bone fill
number of diseased sites that were unresponsive to conventional may occur in selected sites.107,112
therapy, and possibly enhanced treatment results at specific Clinical trials suggest that obtaining new periodontal
locations. Local delivery modalities have shown beneficial clini- attachment or regenerating lost tissues is enhanced by the
cal improvements with regard to probing depth reduction and use of adjunctive surgical technique devices and materials.
gain in clinical attachment.91-94 Furthermore, there are limited Chemical agents that modify the root surface, while promoting
data to suggest that local delivery of antibiotics may also be new attachment, have shown variable results when used in
beneficial in preventing recurrent attachment loss in the ab- humans.113-118 Bone grafting119-125 and guided tissue regeneration
sence of maintenance therapy.90 (GTR) techniques, with or without bone replacement grafts,126-133
Utilization of antibiotics at an individual site will depend may be successful when used at selected sites with advanced
on the discretion of the treating therapist after consultation attachment loss. The use of biologically engineered tissue induc-
with the patient. The greatest potential of local delivery devices tive proteins (e.g., growth factors, extracellular matrix proteins,
may be to enhance therapy at sites that do not respond to and bone morphogenic proteins) to stimulate periodontal or
conventional treatment. Ultimately, the results of local drug osseous regeneration has also shown promise.134-142 Literature
delivery must be evaluated with regard to the magnitude of reviews on periodontal regeneration143,144 and mucogingival
improvement that can be attained relative to disease severity. A therapy145 provide additional information regarding these
more complete review of local drug delivery can be found in therapies.


Regenerative therapy and other treatment modalities can utilized by the clinician at various times over the long-term
be affected by several risk factors (e.g., diabetes and tobacco management of the patient’s periodontal condition.
use) which can diminish periodontal treatment outcomes.146 In
this regard, cigarette smoking is associated with a high risk for References
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149. Preber H, Bergström J. The effect of non-surgical treat- Acknowledgments
ment on periodontal pockets in smokers and non-smokers. This paper was revised by Dr. Paul S. Rosen. It replaces the
J Clin Periodontol 1986;13:319-23. paper entitled Treatment of Gingivitis and Periodontitis which
150. Preber H, Bergström J. Effect of cigarette smoking on was authored by Drs. William F. Ammons, Kenneth L.
periodontal healing following surgical therapy. J Clin Kalkwarf, and Stephen T. Sonis in May 1993 and revised by
Periodontol 1990;17:324-8. Dr. Bruce L. Pihlstrom and William F. Ammons in September
151. American Academy of Periodontology. Tobacco use and 1997. Members of the 2000-2001 Research, Science and Ther-
the periodontal patient (position paper). Chicago, Ill.: apy Committee include: Drs. David Cochran, Chair; Timothy
The American Academy of Periodontology; September Blieden; Otis J. Bouwsma; Robert E. Cohen; Petros Damoulis;
1995. Connie H. Drisko; Joseph P. Fiorellini; Gary Greenstein; Vincent
152. Comar MD, Kollar, Gargiulo AW. Local irritation and J. Iacono; Martha J. Somerman; Terry D. Rees; Angelo Mariotti,
occlusal trauma as co-factors in the periodontal disease Consultant; Robert J. Genco, Consultant; and Brian L. Mealey,
process. J Periodontol 1969;40:193-200. Board Liaison.
153. Polson AM, Meitner SW, Zander HA. Trauma and pro-
gression of marginal periodontitis in squirrel monkeys. III. Individual copies of this position paper may be obtained
Adaptation of interproximal alveolar bone to repetitive by accessing: “http://www.perio.org”. Members of the Amer-
injury. J Periodont Res 1976;11:278-89. ican Academy of Periodontology have permission of the Aca-
154. Polson AM, Meitner SW, Zander HA. Trauma and demy, as copyright holder, to reproduce up to 150 copies of
progression of marginal periodontitis in squirrel monkeys. this document for not-forprofit, educational purposes only. For
IV. Reversibility of bone loss due to trauma alone and information on reproduction of the document for any other
trauma superimposed upon periodontitis. J Periodont Res use or distribution, please contact Rita Shafer at the Academy
1976;11:290-7. Central Office; voice: (312) 573-3221; fax: (312) 573-3225; or
e-mail: rita@perio.org.


ENDORSEMENTS: HEALTHY BEVERAGES
Healthy Beverage Consumption in Early Childhood:

Recommendations from Key National Health and
Nutrition Organizations: Summary of Oral Health
Considerations
How to Cite: American Academy of Pediatric Dentistry. Healthy bev-
erage consumption in early childhood: Recommendations from key
2019 national health and nutrition organizations: Summary of oral health
considerations. The Reference Manual of Pediatric Dentistry. Chicago,
The American Academy of Pediatric Dentistry (AAPD), in its olds, close to half (45 percent) consume a sugar-sweetened
efforts to promote optimal health for children, supports the beverage (SSB) daily, and the prevalence of SSB consumption
2019 technical report and consensus statement on beverage increases throughout childhood. Significant differences in
consumption by young children (aged 0-5 years). These guide- beverage intake by race/ethnicity and income groups in early
lines were developed as part of a collaboration of the Academy childhood have been noted.
of Nutrition and Dietetics (AND), the AAPD, the American Leading medical and nutrition organizations recommend
Academy of Pediatrics (AAP), and the American Heart Asso- breast milk, infant formula, water, and plain milk as part of
ciation (AHA). This cooperative effort transpired under the beverage guidelines for children under age five. They caution
leadership of Healthy Eating Research (HER), a leading nutri- against beverages that are sources of added sugars in young
tion research organization, through funding from the Robert children’s diets, including flavored milks (e.g., chocolate,
Wood Johnson Foundation. strawberry) and sugary and low-calorie sweetened beverages.
To develop the technical report and recommendations, HER In addition, they advise against a wide variety of new beverages
conducted a review of scientific literature, gathering existing on the market targeted to children, such as toddler formulas,
guidelines from national and international bodies and reports caffeinated beverages, and plant-based/non-dairy milks (e.g.,
on early childhood beverage consumption. It also convened almond, rice, oat) that provide no unique nutritional value.
an expert panel of representatives from the AND, AAPD, AAP, The recommendations outlined on the next pages by age
AHA, and a scientific advisory committee. This policy brief are intended for healthy children in the United States and do
is intended to summarize key findings, especially as related to not address medical situations in which specific nutrition
oral health considerations. guidance is needed to manage a health condition.
Establishing healthy dietary patterns in early childhood is Summary of considerations related to oral health:
important to help prevent future diet-related chronic diseases • The overconsumption of unhealthy beverages coupled
and support optimal growth and development and overall with the underconsumption of healthy beverages during
health. Healthy beverage intake is critical in early childhood early childhood can lead to the development of chronic
because beverages can make a significant contribution to die- diet-related diseases including diabetes, obesity, and
tary intake during this period and, thus, may serve as important dental caries.
sources of essential nutrients. However, many beverages con- • Establishing healthy beverage patterns in the first five
tain added sugars and saturated fats, which can be harmful years can promote adequate intake of healthy nutrients
when consumed in excess. Overconsumption of unhealthy while reducing excess consumption of sugars and
beverages along with inadequate consumption of healthy saturated fats.
beverages in early childhood can contribute to chronic diseases,
including dental caries.
Despite the importance of healthy beverages in early
ABBREVIATIONS
childhood, the beverage intake of many young children
AAPD: American Academy of Pediatric Dentistry. AAP: American
diverges from evidence-based recommendations. For example, Academy of Pediatrics. AHA: American Heart Association. AND:
many infants consume cow’s milk and 100 percent juice before Academy of Nutrition and Dietetics. HER: Healthy Eating Research.
their first birthday, which can increase their risk for such LCS: Low-calorie sweeteners. SSB: Sugar-sweetened beverage.
nutrient deficiencies as anemia. Among two- and three-year

• Early life is an important period for the development of uncarbonated, fluoridated drinking water), particularly
flavor and food preferences. Thus, minimizing children’s for beverages consumed outside of meals and snacks.
exposure to sweet-tasting beverages during their early Fluoridated drinking water is a beneficial and inexpensive
years may help reduce their preference for sweetened strategy for reducing dental caries. The vast majority of
food and beverages at older ages. bottled waters do not contain optimal levels of fluoride,
• Strong evidence demonstrates the adverse health effects and some do not contain any fluoride.
of SSBs, which include, but are not limited to, soft • Between one and five years of age, plant milks may be
drinks/soda, fruit drinks, fruit-flavored drinks, sports particularly useful for children with allergies or intoler-
drinks, energy drinks, sweetened waters, and sweetened ances to cow’s milk (about 2.5 percent of children under
coffee and tea beverages. Children from birth to five years three years old are allergic to milk) or to accommodate
old should not consume sugar-sweetened beverages. vegan or certain vegetarian dietary preferences. Children
• For children ages six to 12 months who are eating solid should consume only unsweetened varieties in order to
foods, a small amount (e.g., approximately four to eight avoid additional added sugar in the diet.
ounces total per day) of plain drinking water may be • Little research has examined low-calorie sweeteners (LCS)
offered in an open, sippy, or strawed cup to help famil- intake and sweet taste preferences among young children.
iarize the infant with plain water. The early introduction Given that early childhood is a critical developmental
of water may help children become accustomed to its period and that there is a lack of evidence regarding the
taste. long-term health impact of LCS consumption in young
• Children ages one to five years are encouraged to con- children, children from birth to five years old should not
sume plain drinking water (i.e., unflavored, unsweetened, consume beverages with LCS.
Table. Summary of Beverage Recommendations for Children, Ages 0-5 years a
0-6 months 6-12 months 12-24 months 2-5 years Notes

2-3 years 4-5 years
Plain drinking water
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Plain, pasterurized milk
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100% juice
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a The expert panel did not address breast milk or infant formula as recommendations in these areas vary by the infant’s age, weight, and developmental
milestones and are generally well understood and widely accepted.

Table. Continued
0-6 months 6-12 months 12-24 months 2-5 years Notes
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Plant milk / Non-diary
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beverages
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LQGLFDWHGHJFRZ¶V IHUHQFHVHJYHJDQ QXWULHQWVFRPPRQO\REWDLQHGIURP
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Flavored milk
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QXWULHQWLQWDNHDQGGLHWTXDOLW\
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Toddler milk
UHFRPPHQGHG UHFRPPHQGHG UHFRPPHQGHG UHFRPPHQGHG QXWULWLRQDO YDOXH EH\RQG ZKDW D

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YLGHV DQG PD\ FRQWULEXWH DGGHG
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UHFRPPHQGHG UHFRPPHQGHG UHFRPPHQGHG UHFRPPHQGHG WKHDGYHUVHKHDOWKHIIHFWVRI66%
Sugar-sweetened
beverages ( SSB )
ZKLFK LQFOXGH EXW DUH QRW OLPLWHG

WR VRIW GULQNVVRGD IUXLW GULQNV
IUXLWIODYRUHG GULQNV IUXLWDGHV
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HQHGZDWHUVDQGVZHHWHQHGFRIIHH
DQGWHDEHYHUDJHV
1RW 1RW 1RW 1RW 7KLV UHFRPPHQGDWLRQ LV EDVHG

sweeteners ( LCS)
Beverages with
UHFRPPHQGHG UHFRPPHQGHG UHFRPPHQGHG UHFRPPHQGHG RQH[SHUWRSLQLRQJLYHQWKDWHDUO\

low-calorie
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PHQWDOSHULRGDQGWKHUHLVDODFN
RI HYLGHQFH UHJDUGLQJ WKH ORQJ
WHUP KHDOWK LPSDFWV RI /&6
FRQVXPSWLRQLQ\RXQJFKLOGUHQ
Caffeinated
beverages
1RW 1RW 1RW 1RW &DIIHLQDWHG EHYHUDJHV DUH QRW

UHFRPPHQGHG UHFRPPHQGHG UHFRPPHQGHG UHFRPPHQGHG DSSURSULDWHIRU\RXQJFKLOGUHQ
Notes: All amounts listed are per day, unless otherwise noted; 1 cup = 8 fluid ounces.
• It is ideal for young children to achieve fruit intake goals. The recommendations for juice consumption are
recommendations primarily by eating whole fruits with- considered upper limits for daily servings, not minimum
out added sugars or low-calorie sweeteners. However, a requirements. If consumed, 100 percent juice should be
combination of fruit plus 100 percent fruit juice is pre- part of a meal or snack, not sipped throughout the day.
ferred to the alternative of falling short of fruit intake

• Frequent consumption of between-meal snacks and Bleich SN, Vercammen KA. The negative impact of sugar-
beverages containing sugars, whether added or naturally- sweetened beverages on children’s health: An update of the
occurring, increases the risk for dental caries due to literature. BMC Obesity 2018;5(6):1-27. Available at: “https:
prolonged contact between sugars in the consumed food //bmcobes.biomedcentral.com/track/pdf/10.1186/s40608-
or liquid and cariogenic bacteria on the teeth. To reduce 017-0178-9”. Accessed September 28, 2019.
the risk of caries:
Gordon-Larsen P, The NS, Adair LS. Longitudinal trends in
– Avoid consumption of sugar sweetened beverages
obesity in the United States from adolescence to the third
from a sippy cup or other training cup.
decade of life. Obesity 2009;18(9):1801-4.
– Wean young children from a bottle by age one.
– Do not put children to bed with a bottle containing Kay M, Welker E, Jacquier E, Story M. Beverage consumption
anything but water. patterns among infants and young children (0–47.9 Months):
Data from the feeding infants and toddlers study, 2016.
For the complete consensus statement, visit: Nutrients 2018;10(7):825.
– https://healthyeatingresearch.org/wp-content/uploads/2019/
Marshall TA, Levy SM, Broffitt B, et al. Dental caries and
09/HER-HealthyBeverage-ConsensusStatement.pdf
beverage consumption in young children. Pediatrics 2003;112
For the complete technical report, visit: (3 Pt 1):e184-91. Available at: “https://pediatrics.aappublica
– https://healthyeatingresearch.org/research/technical-scientific- tions.org/content/pediatrics/112/3/e184.full.pdf ”. Accessed
report-healthy-beverage-consumption-in-early-childhood- September 28, 2019.
recommendations-from-key-national-health-and-nutrition-
Okubo H, Crozier SR, Harvey NC, et al. Diet quality across
organizations/
early childhood and adiposity at 6 years: The Southampton
Women’s Survey. Int J Obes 2015;39(10):1456-62.
Bibliography
American Academy of Pediatrics. Maintaining and improving Skinner JD, Carruth BR, Wendy B, Ziegler PJ. Children’s
the oral health of young children. Pediatrics 2014;134(6): food preferences: A longitudinal analysis. J Am Diet Assoc
1224-9. Available at: “https://pediatrics.aappublications. 2002;102(11):1638-47.
org/content/pediatrics/134/6/1224.full.pdf ”. Accessed
U.S. Department of Health and Human Services. Dietary
September 28, 2019.
Guidelines for Americans 2015-2020. 8th ed. 2015. Available
American Dental Association. The facts about bottled water. at: “https://health.gov/dietaryguidelines/2015/resources/2015
J Am Dent Assoc 2003;134(9):1287. Available at: “https:// -2020_Dietary_Guidelines.pdf ”. Accessed September 28,
jada.ada.org/article/S0002-8177(14)65095-9/pdf ”. Accessed 2019.
September 28, 2019.
Birch LL, Doub AE. Learning to eat: Birth to age 2 y. Am J

Clin Nutr 2014;99(3):723S-8S. Available at: “https://
academic.oup.com/ajcn/article/99/3/723S/4577491”. Accessed
September 28, 2019.

'2:1/2$'&203/(7( 0287+02167(5'()(16(.,7
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®
REFERENCE MANUAL V 40 / NO 6 18 / 19
Resources
Supplemental information
to be used as a quick reference
when more detailed information
is not readily accessible, as well
as clinical forms offered to
facilitate excellence in practice.
552 RESOURCES
RESOURCES: GROWTH AND DEVELOPMENT
Dental Growth and Development
Primary Dentition
Calcification Formation Eruption Exfoliation
begins at complete at Maxillary Mandibular Maxillary Mandibular
Central incisors 4th fetal mo 18-24 mo 6-10 mo 5-8 mo 7-8 y 6-7 y

Lateral incisors 4th fetal mo 18-24 mo 8-12 mo 7-10 mo 8-9 y 7-8 y
th
Canines 4 fetal mo 30-39 mo 16-20 mo 16-20 mo 11-12 y 9-11 y
First molars 4th fetal mo 24-30 mo 11-18 mo 11-18 mo 9-11 y 10-12 y
Second molars 4th fetal mo 36 mo 20-30 mo 20-30 mo 9-12 y 11-13 y
Permanent Dentition
Calcification Crown (enamel) Roots Eruption*
begins at complete at complete at Maxillary Mandibular
Central incisiors 3-4 mo 4-5 y 9-10 y 7-8 y (3) 6-7 y (2)

Lateral incisors Maxilla: 10-12 mo 4-5 y 11 y 8-9 y (5) 7-8 y (4)
Mandible: 3-4 mo 4-5 y 10 y
Canines 4-5 mo 6-7 y 12-15 y 11-12 y (11) 9-11 y (6)

First premolars 18-24 mo 5-6 y 12-13 y 10-11 y (7) 10-12 y (8)
Second premolars 24-30 mo 6-7 y 12-14 y 10-12 y (9) 11-13 y (10)
First molars Birth 30-36 mo 9-10 y 5.5-7 y (1) 5.5-7 y (1a)
Second molars 30-36 mo 7-8 y 14-16 y 12-14 y (12) 12-14 y (12a)
Third molars Maxilla: 7-9 y 17-30 y (13) 17-30 y (13a)
Mandible: 8-10 y
* Figures in parentheses indicate order of eruption. Many otherwise normal infants do not conform strictly to the stated schedule.
Copyright © 1933 American Dental Association. All rights reserved. Adapted 2003 by permission.
Logan WHG, Kronfeld R. Development of the human jaws and surrounding structures from birth to the age of fifteen years. J Am Dent Assoc 1933;20(3):379-427.

RESOURCES: GROWTH CHARTS
Growth Charts






RESOURCES: BMI CHARTS
Body Mass Index (BMI) Charts

RESOURCES: BMI CHARTS

RESOURCES: HEALTHY FOOD PATTERNS
Recommended USDA Food Patterns

U.S. Department of Agriculture. Center for Nutrition Policy and Promotion. USDA Food Patterns, 2015.
Available at: “https://www.fns.usda.gov/usda-food-patterns”.

U.S. Department of Agriculture. Center for Nutrition Policy and Promotion. USDA Food Patterns, 2015.
Available at: “https://www.fns.usda.gov/usda-food-patterns”.

RESOURCES: IMMUNIZATION SCHEDULE
Child and Adolescent Immunization Schedule








RESOURCES: CHILD SPEECH AND HEARING
Speech and Language Milestones

What should my child be able to do?
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Reprinted with permission from How does your child hear and talk? (n.d.) Available from the website of the American Speech-Language Hearing Association:
“http://www.asha.org/public/speech/development/chart.htm”. All rights reserved.

RESOURCES: CHILD SPEECH AND HEARING
What should my child be able to do?

Hearing and Understanding 7DONLQJ
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to VFKRRO
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Reprinted with permission from How does your child hear and talk? (n.d.) Available from the website of the American Speech-Language Hearing Association:
“http://www.asha.org/public/speech/development/chart.htm”. All rights reserved.

RESOURCES: MEDICAL HISTORY FORM
Pediatric Medical History

Child’s legal name: ___________________________________________ Nickname: ____________________ Date of birth: _____/____/______
Birth sex: M F Current gender identity: _________ Pronouns: _____ Race/Ethnicity: ____________ Height: ____cm Weight: ____kg
Name/age and relationship of others living in the household: _________________________________________________________________________
_________________________________________________________________________________________________________________________
Primary physician: __________________________ Address/phone: _____________________________________________ Last visit: __________
Medical specialists: __________________________ Address/phone: _____________________________________________ Last visit: __________
Is your child being treated by a physician at this time? Reason ___________________________________________________ YES NO
Is your child taking any medication (prescription or over the counter), vitamins, or dietary supplements? ………………........… YES NO
List name, dose, frequency & date started: ______________________________________________________________
Has your child ever been hospitalized, had surgery or a significant injury, or been treated in an emergency department? ..........… YES NO
List date & describe: _______________________________________________________________________________
Has your child ever had a reaction to or problem with an anesthetic? Describe ______________________________________ YES NO
Has your child ever had a reaction or allergy to an antibiotic, sedative, or other medication? List ________________________ YES NO
Is your child allergic to latex or anything else such as metals, acrylic, or dye? List ____________________________________ YES NO
Is your child up to date on immunizations against childhood diseases? ......................................................................................... YES NO
Is your child immunized against human papilloma virus (HPV)? ................................................................................................. YES NO
Please mark YES if your child has a history of the following conditions. For each “YES”, provide details in the box at the bottom of this list. Mark NO after each line if none
of those conditions applies to your child.
Complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions ……..……………....... YES NO
Problems with physical growth or development ………………...……..………...………………………………………....... YES NO
Sinusitis, chronic adenoid/tonsil infections ……………………………………………………………….............................. YES NO
Sleep apnea/snoring, mouth breathing, or excessive gagging ……………………..………………………………………...... YES NO
Congenital heart defect/disease, heart murmur, rheumatic fever, or rheumatic heart disease ……………………………........ YES NO
Irregular heart beat or high blood pressure …………………………………………………………………………….......... YES NO
Asthma, reactive airway disease, wheezing, or breathing problems ………………..……………..………………………....... YES NO
Cystic fibrosis ………………………………………………………………………………………………………….......... YES NO
Frequent colds or coughs, or pneumonia …….………………………………………………...……………………............. YES NO
Frequent exposure to tobacco smoke ............................................……………………………………………………........... YES NO
Jaundice, hepatitis, or liver problems …………………………………………………………………………………........... YES NO
Gastroesophageal/acid reflux disease (GERD), stomach ulcer, or intestinal problems ……………..……………………........ YES NO
Lactose intolerance, food allergies, nutritional deficiencies, or dietary restrictions ………………………………………........ YES NO
Prolonged diarrhea, unintentional weight loss, concerns with weight, or eating disorder …………..……………………....... YES NO
Bladder or kidney problems ……………………………………..…………………………………………………..…........ YES NO
Fine/gross motor deficits, arthritis, limited use of arms or legs, muscle/bone/joint problems, or scoliosis ……………..…...... YES NO
Rash/hives, eczema, or skin problems …………………………………………………………………………………........... YES NO
Impaired vision, visual processing, hearing, or speech …………………………….……………………………...….............. YES NO
Developmental disorders, learning problems/delays, or intellectual disability …………………….…..…………………....... YES NO
Cerebral palsy, brain injury, epilepsy, or convulsions/seizures ……………………………………………..……………......... YES NO
Autism/autism spectrum disorder ……………………………………………………………………………...………........ YES NO
Recurrent or frequent headaches/migraines, fainting, or dizziness …………………………………………..…………......... YES NO
Hydrocephaly or placement of a shunt (ventriculoperitoneal, ventriculoatrial, ventriculovenous) ……………..…...……...... YES NO
Attention deficit/hyperactivity disorder (ADD/ADHD) ………………………………………………………………......... YES NO
Behavioral, emotional, communication, or psychiatric problems/treatment ……………………………………………......... YES NO
Abuse (physical, psychological, emotional, or sexual) or neglect ……………………………………………………….......... YES NO
Diabetes, hyperglycemia, or hypoglycemia …………………………………………………………………………….......... YES NO
Precocious puberty or hormonal problems ………………………………………………………………………………...... YES NO
Thyroid or pituitary problems …………………………………………………………………………………………......... YES NO
Anemia, sickle cell disease/trait, or blood disorder ………………………………………………………………………....... YES NO
Hemophilia, bruising easily, or excessive bleeding ………………………………………………………………………....... YES NO
Transfusions or receiving blood products ……………………………………………………………………………............ YES NO
Cancer, tumor, or other malignancy; chemotherapy, radiation therapy, or bone marrow or organ transplant ……………...... YES NO
Mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus (CMV), methicillin resistant staphylococcus aureus (MRSA),
sexually transmitted disease (STD), or human immunodeficiency virus (HIV)/AIDS .…..………...................................... YES NO
PROVIDE DETAILS HERE: _________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Is there any other significant medical history pertaining to this child or his/her family that the dentist should be told? ............... YES NO
If YES, describe _________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
What is your primary concern about your child’s oral health? ____________________________________________________________________________
How would you describe:
your child’s oral health? Excellent Good Fair Poor
your oral health? Excellent Good Fair Poor
the oral health of your other children? Excellent Good Fair Poor Not applicable
Is there a family history of cavities? YES NO If yes, indicate all that apply: Mother Father Brother Sister
Does your child have a history of any of the following? For each YES response, please describe:
Inherited dental characteristics YES NO ______________________________________________________________________
Mouth sores or fever blisters YES NO ______________________________________________________________________
Bad breath YES NO ______________________________________________________________________
Bleeding gums YES NO ______________________________________________________________________
Cavities/decayed teeth YES NO ______________________________________________________________________
Toothache YES NO ______________________________________________________________________
Injury to teeth, mouth, or jaws YES NO ______________________________________________________________________
Clinching/grinding his/her teeth YES NO ______________________________________________________________________
Jaw joint problems (popping, etc.) YES NO ______________________________________________________________________
Excessive gagging YES NO ______________________________________________________________________
Sucking habit after one year of age YES NO If yes, which: Finger Thumb Pacifier Other For how long? __________
How often does your child brush his/her teeth? ________ times per ___________ Does someone help your child brush? YES NO
How often does your child floss his/her teeth? Never Occasionally Daily Does someone help your child floss? YES NO
What type of toothbrush does your child use? Hard Medium Soft Unsure
What toothpaste does your child use? __________________________________________
What is the source of your drinking water at home? City/community supply Private well Bottled water
Do you use a water filter at home? YES NO If YES, type of filtering system: _______________________
Please check all sources of fluoride your child receives:
Drinking water Toothpaste Over-the-counter rinse Prescription rinse/gel Prescription drops/tablets/vitamins
Fluoride treatment in the dental office Fluoride varnish by pediatrician/other practitioner Other: ______________________
Does your child regularly eat 3 meals each day? YES NO
Is your child on a special or restricted diet? YES NO If YES, describe: _________________________________
Is your child a ‘picky eater’? YES NO If YES, describe: _________________________________
Does your child have a diet high in sugars or starches? YES NO If YES, describe: _________________________________
Do you have any concerns regarding your child’s weight? YES NO If YES, describe: _________________________________
How frequently does your child have the following?
Snacks between meals Rarely 1-2 times/day 3 or more times/day Product _____________________
Candy or other sweets Rarely 1-2 times/day 3 or more times/day Type _______________________
Chewing gum Rarely 1-2 times/day 3 or more times/day Usual snack __________________
Soft drinks* Rarely 1-2 times/day 3 or more times/day Product _____________________
(*such as juice, fruit-flavored drinks, sodas, colas, carbonated beverages, sweetened beverages, sports drinks, or energy drinks)
Please note other significant dietary habits: _______________________________________________________________________________________
Does your child participate in any sports or similar activities? YES NO If YES, list: ______________________________________
Does your child wear a mouthguard during these activities? YES NO If YES, type: _____________________________________
Has your child been examined or treated by another dentist? YES NO
If YES: Date of first visit: ______________ Date of last visit: _____________ Reason for last visit: ________________________________
Were x-rays taken of the teeth or jaws? YES NO Date of most recent dental X-rays: _____________________
Has your child ever had orthodontic treatment (braces, spacers, or other appliances)? YES NO If YES, when? ____________________
Has your child ever had a difficult dental appointment? YES NO If YES, describe: ___________________________________
How do you expect your child will respond to dental treatment? Very well Fairly well Somewhat poorly Very poorly
Is there anything else we should know before treating your child? YES NO
If yes, describe: ____________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_____________________________________ ______________________ ______________ ___________________________________
Signature of parent/guardian Relationship to child Date Signature of staff member reviewing history
MEDICAL / DENTAL HISTORY UPDATE

Is your child being treated by a physician at this time? Reason _______________________________________________________ YES NO
Is your child taking any medication (prescription or over the counter), vitamins, or dietary supplements? ………………..............….. YES NO
List name, dose, frequency, & date started: _________________________________________________________________
Has your child had any illness, surgery, injury, allergic reaction, or medical emergency in the past year? ………..................…………. YES NO
Describe: __________________________________________________________________________________________
Has your child ever had a reaction to or problem with an anesthetic? Describe: __________________________________________ YES NO
Has your child ever had a reaction or allergy to an antibiotic, sedative, or other medication? List: ____________________________ YES NO
Is your child allergic to latex or anything else such as metals, acrylic, or dye? List _________________________________________ YES NO
Have there recently been any significant changes/disruptions to your child’s family, home, or school routines? ……………................ YES NO
Describe: __________________________________________________________________________________________
What is your primary concern regarding your child’s oral health? _____________________________________________________
Has your child had any tooth pain or injury to the mouth/teeth/jaws since last visiting our office? ………………............................... YES NO
Describe: __________________________________________________________________________________________
Has your child’s diet changed significantly since his/her last dental visit? Describe: _______________________________________ YES NO
Has your child been treated by another dentist/dental professional since last visiting our office? Reason: ______________________ YES NO
Is there any other change in the child’s medical, dental, or family history that the dentist should be told? ............................................ YES NO
Describe: ___________________________________________________________________________________________
_____________________________________ _________________ _____________ ____________________________________
Signature of parent/guardian Relationship to child Date Signature of staff member reviewing history
SUPPLEMENTAL HISTORY QUESTIONS FOR AN INFANT / TODDLER
Was your child born prematurely? YES NO If YES, what week? _______________________
What was your child’s birth weight? _____________
How long was your child breast-fed? N/A less than 6-11 12-17 18-23 2 years or
6 months months months months more
How long was your child bottle-fed? N/A less than 6-11 12-17 18-23 2 years or
Do/did you feed your child infant formula? YES NO If YES, what type? (check one): Ready to use Powdered
Liquid concentrate
Does/did your child sleep with a bottle? YES NO If YES, content of bottle? ________________________________
Does/did your child use a no-spill training cup YES NO
(sippy cup)?
Child’s age (in months) when first tooth appeared in mouth _________________
Has your child experienced any teething problems? YES NO
When did you begin brushing his/her teeth? N/A before age 6-11 12-17 18-23 2 years or
When did you begin using toothpaste? N/A before age 6-11 12-17 18-23 2 years or
Who is your child’s primary care taker during the day? ___________________________ during the evening? _________________________________
Name/age of siblings at home: _______________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_____________________________ _____________________________ ___________ ___________________________________
Signature of parent/guardian Relationship to child Date Signature of staff member reviewing history
SUPPLEMENTAL HISTORY QUESTIONS FOR AN ADOLESCENT PATIENT (to be completed by the patient)
For each YES response, please describe:
Do you have any concerns about your mouth, teeth, or oral health? NO YES _______________________________________________
Have you recently experienced any dental/oral pain? NO YES _______________________________________________
Do you have any concerns with the appearance of your teeth or smile? NO YES _______________________________________________
Do you bleach your teeth? NO YES ________________________________________________
Have there been any recent changes in your dietary habits? NO YES ________________________________________________
Are you taking any dietary or herbal supplements? NO YES ________________________________________________
Do you participate in sports or high speed activities (for example NO YES _______________________________________________
skiing, four-wheeling, motorcycling)?
We recognize that patients may engage in certain behaviors/activities that can have significant consequences on their oral health and/or general health.
In addition, medicines that we use to treat oral conditions may interact with drugs (prescription, over-the-counter, or recreational) and other substances a
patient might be using. Therefore, we encourage our adolescent patients to answer all of the following questions truthfully. If you prefer not to answer an
item, we hope you will discuss any concerns confidentially with your dentist.
Do you have any history of:

Oral habits (chewing fingernails, clenching/grinding teeth, etc.) NO YES PREFER NOT TO ANSWER
Tobacco use (cigarette, pipe, cigar, bidi, snuff, spit, chew, etc.) NO YES PREFER NOT TO ANSWER
Electronic cigarette (e-cig) use NO YES PREFER NOT TO ANSWER
Eating disorder (anorexia, bulimia, etc.) NO YES PREFER NOT TO ANSWER
Oral piercings/jewelry (including grill) NO YES PREFER NOT TO ANSWER
Alcohol or recreational drug use/prescription abuse NO YES PREFER NOT TO ANSWER
Inhalant use/abuse (such as huffing) NO YES PREFER NOT TO ANSWER
Sexual activity (including oral sex) NO YES PREFER NOT TO ANSWER
Abuse (physical, sexual, verbal, mental) NO YES PREFER NOT TO ANSWER
Anxiety, depression, or feeling helpless/hopeless NO YES PREFER NOT TO ANSWER
Females: Are you pregnant or possibly pregnant? NO YES
Is there anything you would like to discuss confidentially with your dentist? NO YES
Would you like to discuss a referral to a family dentist or general dentist because of your age? NO YES
_____________________________________ _______________ ________________________________________________
Signature of patient Date Signature of staff member reviewing history

RESOURCES: SDF CHAIRSIDE GUIDE
Chairside Guide: Silver Diamine Fluoride in the

Management of Dental Caries Lesions*
Dental caries affects about one out of four children aged 2-5 years.1 Silver diamine fluoride (SDF), recently approved for use in
the United States, has been shown to be efficacious in arresting caries lesions.2,3 It is a valuable therapy which may be included
as part of a caries management plan for patients. Caries lesions treated with SDF usually turn black and hard. Stopping the
caries process in all targeted lesions may take several applications of SDF, and reapplication may be necessary to sustain arrest.
Active cavitated caries lesions before application of SDF SDF-treated lesions with temporary gingival staining
Case selection for application of silver diamine fluoride • A protective coating may be applied to the lips and skin
Patients who may benefit from SDF include those: to prevent a temporary henna-appearing tattoo that can
• With high caries risk who have active cavitated caries occur if soft tissues come into contact with SDF.
lesions in anterior or posterior teeth; • Isolate areas to be treated with cotton rolls or other isola-
• Presenting with behavioral or medical management chal- tion methods. If applying cocoa butter or any other product
lenges and cavitated caries lesions; to protect surrounding gingival tissues, use care to not
• With multiple cavitated caries lesions that may not all inadvertently coat the surfaces of the caries lesions.
be treated in one visit; • Caution should be taken when applying SDF on primary
• With dental caries lesions that are difficult to treat; and teeth adjacent to permanent anterior teeth that may have
• Without access to or with difficulty accessing dental care. non-cavitated (white spot) lesions to avoid inadvertent
Criteria for tooth selection include: staining.
• No clinical signs of pulpal inflammation or reports of • Careful application with a microbrush should be adequate
unsolicited/spontaneous pain. to prevent intraoral and extraoral soft tissue exposure. No
• Cavitated caries lesions that are not encroaching on the more than one drop of SDF should be used for the entire
pulp. If possible, radiographs should be taken to assess appointment.
depth of caries lesions. • Dry lesion with gentle flow of compressed air.
• Cavitated caries lesions on any surface as long as they are • Bend micro sponge brush. Dip brush into SDF and dab
accessible with a brush for applying SDF. (Orthodontic on the side of the plastic dappen dish to remove excess
separators may be used to help gain access to proximal liquid before application. Apply SDF directly to only the
lesions.) affected tooth surface. Remove excess SDF with gauze,
SDF can be used prior to restoration placement and as part cotton roll, or cotton pellet to minimize systemic absorption.
of caries control therapy.4 Informed consent, particularly high- • Application time should be at least one minute if possible.
lighting expected staining of treated lesions, potential staining (Application time likely will be shorter in very young and
of skin and clothes, and need for reapplication for disease difficult to manage patients. When using shorter applica-
control, is recommended. tion periods, monitor carefully at post-operative and recall
visits to evaluate arrest and consider reapplication.)
Clinical application of silver diamine fluoride • Apply gentle flow of compressed air until medicament is
• Remove gross debris from cavitation to allow better SDF dry. Try to keep isolated for as long as three minutes.
contact with denatured dentin. • The entire dentition may be treated after SDF treatment
• Carious dentin excavation prior to SDF application is not with five percent sodium fluoride varnish to help prevent
necessary. As excavation may reduce proportion of arrested caries on the teeth and sites not treated with SDF.
caries lesions that become black, it may be considered for
esthetic purposes. * Refer to AAPD Clinical Practice Guideline: Crystal YO, Marghalani AA, Ureles SD, et
al. Use of silver diamine fluoride for dental caries management in children and
adolescents, including those with special health care needs. Pediatr Dent 2017;39
(5):E135-E145. ( Available at: http://www.aapd.org/policies/)

RESOURCES: SDF CHAIRSIDE GUIDE
Follow-up 2. Gao SS, Zhang S, Mei ML, Lo EC, Chu CH. Caries
Estimations of SDF effectiveness in arresting dental caries remineralisation and arresting effect in children by pro-
lesions range from 47 to 90 percent with one-time application fessionally applied fluoride treatment – A systematic
depending on size of the cavity and tooth location.4-7 Anterior review. BMC Oral Health 2016;16:12.
teeth have higher rates of arrest than posterior teeth.5 There- 3. Duangthip D, Jiang M, Chu CH, Lo EC. Restorative
fore, follow-up for evaluation of caries arrest is advisable.2-3 approaches to treat dentin caries in preschool children:
• Follow-up at 2-4 weeks after initial treatment to check Systematic review. Eur J Paediatr Dent 2016;17(2):
the arrest of the lesions treated. 113-21.
• Reapplication of SDF may be indicated if the treated 4. Crystal YO, Niederman R. Silver diamine fluoride treat-
lesions do not appear arrested (dark and hard). Addi- ment considerations in children’s caries management:
tional SDF can be applied at recall appointments as Brief communication and commentary. Pediatr Dent
needed, based on the color and hardness of the lesion 2016;38(7):466-71.
or evidence of lesion progression. 5. Fung M, Duangthip D, Wong M, Lo E, Chu C. Arresting
• Caries lesions can be restored after treatment with SDF. dentine caries with different concentration and perio-
• When lesions are not restored after SDF therapy, bi- dicity of silver diamine fluoride. JDR Clin Transl Res
annual reapplication shows increased caries arrest rate 2016;1(2):143-52.
versus a single application. 6. Llodra JC, Rodriguez A, Ferrer B, Menardia V, Ramos T,
Morato M. Efficacy of silver diamine fluoride for caries
References reduction in primary teeth and first permanent molars
1. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental of schoolchildren: 36-month clinical trial. J Dent Res
caries and sealant prevalence in children and adolescents 2005;84(8):721-4.
in the United States, 2011–2012. NCHS data brief, no 7. Zhi QH, Lo ECM, Lin HC. Randomized clinical trial
191. Hyattsville, Md.: National Center for Health Stat- on effectiveness of silver diamine fluoride and glass
istics. 2015. Available at: “https://www.cdc.gov/nchs/ ionomer in arresting dentine caries in preschool children.
products/databriefs/db191.htm”. Accessed September 6, J Dent 2012;40(11):962-7.
®
2017. (Archived in WebCite at: “http://www.webcita
tion.org/6tX0D6qO1”)

RESOURCES: ACUTE INJURIES
Acute Traumatic Injuries: Assessment and Documentation

PDWLHQWQDPH ___________________________________ 'DWHRIELUWK ______________ 'DWH___________ 7LPH___________
$FFRPSDQLHGE\ __________________________________________ 5HIHUUHGE\ ___________________________________________
MEDICAL HISTORY HISTORY OF THE INCIDENT MANAGEMENT PRIOR TO EXAM

$OOHUJLHV 1R Yes ______________________ 'DWH WLPHRILQMXU\BBBBBBBBBBBBBBBBBBBB %\ZKRP"BBBBBBBBBBBBBBBBBBBBBBBBBBBBB
0HGLFDWLRQV 1R Yes ___________________ 7LPHHODSVHGVLQFHLQMXU\BBBBBBBBBBBBBBBB 'HVFULEH
/DVWWHWDQXVLQRFXODWLRQ______________________ :KRZLWQHVVHGHYHQWBBBBBBBBBBBBBBBBBBB
2WKHUVLJQLILFDQWPHGLFDOKLVWRU\ 'HVFULSWLRQZKDWZKHUHKRZRFFXUHG
HISTORY
COMPLAINTS AND REPORTED CONDITIONS

$OWHUHGRULHQWDWLRQPHQWDOVWDWXV 1R Yes 3DLQRQRSHQLQJFORVLQJPRXWK 1R Yes 0LVVLQJDYXOVHGWRRWK 1R Yes
+HDGDFKHQDXVHDYRPLWLQJ 1R Yes $EQRUPDOSDLQIXORFFOXVLRQ 1R Yes :DVPLVVLQJWRRWKIRXQG" 1R Yes
+HPRUUKDJHIURPHDUVQRVH 1R Yes 6SRQWDQHRXVGHQWDOSDLQ 1R Yes 2WKHUFRPSODLQWV 1R Yes
/RVVRIFRQVFLRXVQHVV 1R Yes 7RRWKVHQVLWLYHWRDLUWKHUPDOFKDQJH 1R Yes 3UHYLRXVGHQWDOWUDXPD 1R Yes
1HFNSDLQ 1R Yes 'LVSODFHGRUORRVHQHGWRRWK 1R Yes 8VHRIRUDODSSOLDQFH 1R Yes
2WKHUERGLO\LQMXULHV 1R Yes )UDFWXUHGWRRWK 1R Yes 1RQQXWULWLYHRUDOKDELW 1R Yes
'HVFULSWLRQRISRVLWLYHILQGLQJV
CRANIOFACIAL ASSESSMENT
EXTRAORAL EXAM
&UDQLDOQHUYHGHILFLW 1R Yes +HPRUUKDJHGUDLQDJH 1R Yes /DFHUDWLRQ 1R Yes %XUQV 1R Yes
6XVSHFWHGIDFLDOIUDFWXUH1R Yes 6ZHOOLQJ1R Yes $EUDVLRQ1R Yes )RUHLJQERG\1R Yes
70-GHYLDWLRQDV\PPHWU\1R Yes Contusion 1R Yes 3XQFWXUH1R Yes 2WKHUILQGLQJ1R Yes
SOFT TISSUES INJURIES DIAGRAM OF INJURIES

/LSV 1R Yes %XFFDOPXFRVD1R Yes 3DODWH1R Yes
Frenum 1R Yes 7RQJXH 1R Yes Other 1R Yes
1R Yes
*LQJLYD )ORRURIPRXWK1R Yes
INTRAORAL EXAMINATION
OCCLUSAL ASSESSMENT
0RODUFODVVLILFDWLRQR______ L______ &URVVELWH 1R Yes
&DQLQHFODVVLILFDWLRQR______ L______ 0LGOLQHGHYLDWLRQ 1R Yes
2YHUELWHBBBBBBBB ,QWHUIHUHQFHV1R Yes OTHER COMMENTS
2YHUMHWPPBBBBBBBB $SSOLDQFHSUHVHQW1R Yes

RESOURCES: ACUTE INJURIES
7227+180%(56
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CHECK IF PERFORMED
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This sample form, developed by the American Academy of Pediatric Dentistry, is provided as a practice tool for pediatric dentists and other dentists treating children. It was developed by
experts in pediatric dentistry, and offered to facilitate excellence in practice. However, this form does not establish or evidence a standard of care. In issuing this form, the American Academy
of Pediatric Dentistry is not engaged in rendering legal or other professional advice. If such services are required, competent legal or other professional counsel should be sought.
RESOURCES: AVULSED PERMANENT TOOTH
Acute Management of an Avulsed Permanent

Tooth with an Open Apex ( Apex >1 mm)
Instructions to Individual at Site of Avulsion:
• Seek medical attention if loss of consciousness, signs of neurological impairment, or other major medical concerns.
• Rinse avulsed tooth gently in milk, saline, or saliva; care not to touch root with fingers.
• If possible, replant avulsed tooth.
• If unable to replant tooth, place in physiologic storage medium (milk, Hank’s Balanced Salt Solution [HBSS], saliva, or saline).
• Seek immediate dental treatment.
?
Upon Arrival to Dental Facility:
• Perform general neurological assessment (See also Acute Traumatic Injuries: Assessment and Documentation1).
• If tooth was not previously replanted or stored in physiologic medium, rinse the root structure with gentle stream of saline until all visible
contaminants are removed and store in physiologic medium.
• Review medical history (including tetanus immunization status) and details of injury.
• Complete clinical and radiographic evaluations.
• Consider taking photographs.
• Evaluate for abuse.
? ?
Tooth has been replanted before Tooth has not been reimplanted prior to arrival. (Prognosis, but not treatment, will change based
arrival to the dental facility. on placement in physiologic storage medium versus dry storage before arrival to dental facility.2)
?
Preparation for Replantation:
• Anesthetize area, giving consideration to using block injection techniques and no vasoconstrictor.
• Irrigate socket with gentle stream of sterile saline, removing coagulum.
? ?
Confirmation of Positioning: Replantation:
?
• Verify the correct position of • Replant tooth slowly and gently.

the tooth clinically and
radiographically.
• Reposition if necessary.
?
Stabilization:
• Stabilize the tooth using a passive, flexible wire or nylon fishing line bonded with composite. Placement should allow area to be cleansable.
• Exception: Alveolar or jaw fracture requires a rigid splint.
?
Postoperative Management: Prescriptions, Splint Removal, and Follow-Up
• Prescribe 7-day course of antibiotics (e.g., amoxicillin or penicillin; alternative for penicillin-allergic patients; doxycycline has demonstrated
anti-resorptive, anti-osteoclastic, anti-inflammatory, and antibacterial effects but is not recommended for patients <12 years of age).
• Prescribe chlorhexidine mouth rinse 2 times/day for 2 weeks.2
• Refer to medical professional for tetanus booster as needed.
• At 2 weeks, remove splint (unless bony fracture occurred) and evaluate clinically and radiographically for pulpal revascularization, infection,
pulpal necrosis, and root resorption.
• Initiate pulpal revascularization, apexification, or root canal treatment as soon as definitive clinical and/or radiographic pathology presents.2
• Frequent, regular follow-up evaluations (e.g., every 4 weeks) are indicated initially.
Adapted with permission: McIntyre J, Lee J, Trope M, Vann WJ. Permanent tooth replantation following avulsion: Using a decision tree to achieve the best outcome. Pediatr Dent 2009;31(2):137-44.
References
1. American Academy of Pediatric Dentistry. Acute traumatic injuries: Assessment and documentation. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
2. Fouad AF, Abbott PV, Tsilingaridis G, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent
teeth. Dent Traumatol 2020;36:331-342. Available at: “https://doi.org/10.1111/edt.12573”.
RESOURCES: AVULSED PERMANENT TOOTH
Acute Management of an Avulsed Permanent

Tooth with an Closed Apex ( Apex <1 mm)
Instructions to Individual at Site of Avulsion:
• Seek medical attention if loss of consciousness, signs of neurological impairment, or other major medical concerns.
• Rinse avulsed tooth gently in milk, saline, or saliva; care not to touch root with fingers.
• If possible, replant avulsed tooth.
• If unable to replant tooth, place in physiologic storage medium (milk, Hank’s Balanced Salt Solution [HBSS], saliva, or saline).
• Seek immediate dental treatment.
?
Upon Arrival to Dental Facility:
• Perform general neurological assessment (See also Acute Traumatic Injuries: Assessment and Documentation1).
• If tooth was not previously replanted or stored in physiologic medium, rinse the root structure with gentle stream of saline until all visible
contaminants are removed and store in physiologic medium.
• Review medical history (including tetanus immunization status) and details of injury.
• Complete clinical and radiographic evaluations.
• Consider taking photographs.
• Evaluate for abuse.
? ?
Tooth has been replanted before Tooth has not been reimplanted prior to arrival. (Prognosis, but not treatment, will change based
arrival to the dental facility. on placement in physiologic storage medium versus dry storage before arrival to dental facility.2)
?
Preparation for Replantation:
• Anesthetize area, giving consideration to using block injection techniques and no vasoconstrictor.
• Irrigate socket with gentle stream of sterile saline, removing coagulum.
? ?
Confirmation of Positioning: Replantation:
?
• Verify the correct position of • Replant tooth slowly and gently.

the tooth clinically and
radiographically.
• Reposition if necessary.
?
Stabilization:
• Stabilize the tooth using a passive, flexible wire or nylon fishing line bonded with composite. Placement should allow area to be cleansable.
• Exception: Alveolar or jaw fracture requires a rigid splint.
?
Postoperative Management: Prescriptions, Root Canal Treatment, Splint Removal, and Follow-Up
• Prescribe 7-day course of antibiotics (e.g., amoxicillin or penicillin; alternative for penicillin-allergic patients; doxycycline has demonstrated
anti-resorptive, anti-osteoclastic, anti-inflammatory, and antibacterial effects but is not recommended for patients <12 years of age).
• Prescribe chlorhexidine mouth rinse 2 times/day for 2 weeks.2
• Refer to medical professional for tetanus booster as needed.
• Initiate root canal treatment (e.g. calcium hydroxide) within 2 weeks of replantation.2
• Splint removal at 2 weeks; rigid splint placed for bony fracture should remain for 4 weeks.
• Follow-up evaluations: 1 month, 3 months, 6 months, 12 months, and annually for 5 years.
Adapted with permission: McIntyre J, Lee J, Trope M, Vann WJ. Permanent tooth replantation following avulsion: Using a decision tree to achieve the best outcome. Pediatr Dent 2009;31(2):137-44.
References
1. American Academy of Pediatric Dentistry. Acute traumatic injuries: Assessment and documentation. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
2. Fouad AF, Abbott PV, Tsilingaridis G, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent
teeth. Dent Traumatol 2020;36:331-342. Available at: “https://doi.org/10.1111/edt.12573”.
RESOURCES: PREPARING FOR SEDATION VISIT
Preparing for Your Child’s Sedation Visit

Patient: ______________________________ Sedation appointment: ___________ at _______AM/PM
We have recommended sedation for your child’s safety and comfort during dental procedures. Sedation can help increase
cooperation and reduce anxiety and/or discomfort associated with dental treatment. Various medications can be used to sedate
a child; medicines will be selected based upon your child’s overall health, level of anxiety, and dental treatment recommenda-
tions. Once the medications have been administered, it may take up to an hour before your child shows signs of sedation
and is ready for dental treatment. Most children become relaxed and/or drowsy and may drift into a light sleep from which
they can be aroused easily. Unlike general anesthesia, sedation is not intended to make a patient unconscious or unresponsive.
Some children may not experience relaxation but an opposite reaction such as agitation or crying. These also are common
responses to the medicines and may prevent us from completing the dental procedures. In any case, our staff will observe
your child’s response to the medications and provide assistance as needed.
You, as parent/legal guardian, play a key role in your child’s dental care. Children often perceive a parent’s anxiety which
makes them more fearful. They tolerate procedures best when their parents understand what to expect and prepare them for
the experience. If you have any questions about the sedation process, please ask. As you become more confident, so will
your child. For your child’s safety, you must follow the instructions below.
Prior to your child’s sedation appointment:

• Please notify our office of any change in your child’s health and/or medical condition. Fever, ear infection, nasal or chest
congestion, or recent head trauma could place your child at increased risk for complications. Should your child become
ill just prior to a sedation appointment, contact our office to see if it is necessary to postpone the sedation.
• Tell us about any prescribed, over-the-counter, or herbal medications your child is taking. Check with us to see if routine
medications should be taken the day of the sedation. Also, report any allergies or reactions to medications that your
child has experienced.
• Food and liquids must be restricted in the hours prior to sedation. Fasting decreases the risk of vomiting and aspirating
stomach contents into the lungs, a potentially life-threatening problem. We will not proceed with the sedation if you
do not comply with the following requirements.
TYPE OF FOOD / LIQUID MINIMUM FASTING PERIOD
Clear liquids: water, fruit juices without pulp, carbonated beverages, clear tea, black coffee. 2 hours before sedation
Human milk 4 hours before sedation
Infant formula, non-human milk, and light meal (toast and clear liquid) 6 hours before sedation
• Dress your child in loose-fitting, comfortable clothing. This will allow us to place monitors that evaluate your child’s
response to the medications and help ensure your child’s safety. These monitors may measure effects on your child’s
breathing, heart rate, and blood pressure.
• Try not to bring other children to this appointment so you can focus your attention on your child undergoing the
sedation.
• If you will be traveling home by automobile or if you must bring any other children with you to this appointment, it
is preferable to have two adults accompany the patient home. On the way home, one individual should be able to
observe the child’s breathing without any distractions, especially if the patient falls asleep while in the car or safety seat.

RESOURCES: PREPARING FOR SEDATION VISIT
During the sedation appointment:

• If any sedative medications are administered before your child is taken to the treatment room, we will ask you to watch
your child closely as he/she may become sleepy, dizzy, unsteady, uncoordinated, or irritable. You will need to remain
next to your child to prevent injuries that may occur from stumbling/falling. Keeping your child calm but distracted
from the unfamiliar surroundings often is helpful.
• You, as the child’s parent/legal guardian, must remain at the office throughout the sedation appointment. You may not
leave the office for any reason.
• The doctor and staff will evaluate your child’s health status before he/she will be discharged home. Children recover from
effects of sedatives at different rates so be prepared to remain at our office until the doctor has determined your child
is stable and the after-effects are minimal. At discharge, your child should be responsive but may be drowsy, crying, or fussy.
After the sedation appointment:

• Once home, your child will still be drowsy and must remain under adult supervision until fully recovered from the effects
of the sedation. If your child wants to sleep, position your child on his/her side with the head supported and the chin up.
During this period, check your child’s breathing and airway every three to five minutes. If your child is snoring, reposition
the head until the snoring disappears and your child breathes normally. If breathing becomes abnormal or you are unable
to arouse your child, contact emergency services (call 911 or ___________________) immediately.
• Nausea and vomiting are occasional side effects of sedation. If vomiting occurs, immediately clear the material from your
child’s mouth. Once again, be sure that breathing is normal. If breathing becomes abnormal or you are unable to arouse
your child, contact emergency services (call 911 or ___________________) immediately. If vomiting persists for 20
to 40 minutes, contact our office immediately.
• Your child may be drowsy for some time after the sedation appointment. Restrict activities for the remainder of the day.
Prohibit potentially harmful activities such as bike riding, swimming, using playground equipment, or any activity
where balance is important.
• In addition to the sedative medications, we often use local anesthetic to numb the mouth during dental treatment. The
numbness usually lasts two to four hours. Watch to see that your child does not bite, scratch, or injure the cheek, lips, or
tongue during this time.
• Children may be irritable after treatment. If this occurs, stay with your child and provide a calm environment. If you
®
believe the irritability is caused by discomfort, you may give your child acetaminophen (Tylenol ) or ibuprofen (Advil , ®
®
Motrin ). Follow the instructions on the bottle for dosing based upon your child’s age/weight.
• Once your child is alert, you may give him/her sips of clear liquids to prevent nausea and dehydration. Small drinks taken
repeatedly are preferable to large amounts. The first meal should be something light and easily digestible (e.g., apple sauce,
®
soup, Jell-O ). Do not give fatty or spicy foods (e.g., milk, cheese, yogurt, French fries, tacos, salsa).
• A slight fever (temperature to 100.5° Fahrenheit) is not uncommon after sedation. You may give your child acetaminophen
® ® ®
(Tylenol ) or ibuprofen (Advil , Motrin ). Follow the instructions on the bottle for dosing based upon your child’s age/
weight. Because dehydration may cause a slight increase in temperature, clear fluids may help correct this condition. If a
higher fever develops or the fever persists, call our office.
• Please feel free to call the office for any questions or concerns that you might have.
• Additional instructions: ______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Contact numbers: Office: ___________________________________ After hours: _______________________________

RESOURCES: SEDATION RECORD
Sedation Record
Patient Selection Criteria Date: ________________________
Patient: ____________________________________ Birth Sex M F DOB ____/____/______ Weight: ________kg Height: ________cm
Physician name/phone number: ______________________________________________________ BMI: __________ BMI% for age: _________
Indication for sedation: Fearful/anxious patient for whom basic behavior guidance techniques have not been successful
Patient unable to cooperate due to lack of psychological or emotional maturity and/or mental, physical, or medical disability
To protect patient’s developing psyche
To reduce patient’s medical risk
Medical history/review of systems (ROS) NO YES* Describe positive findings: ___________ Airway Assessment NO YES*
Allergies &/or previous adverse drug reactions ________________________________ Limited neck mobility
Current medications (including OTC, herbal) ________________________________ Micro/retrognathia
Relevant diseases, physical/neurologic impairment ________________________________ Limited oral opening
Previous sedation/general anesthetics ________________________________ Macroglossia
Snoring, obstructive sleep apnea, mouth breathing ________________________________ Brodsky grading scale: 1 2 3 4
Relevant birth, family, or social history ________________________________ Mallampati classification: I I I III IV
For female: Post-menarchal ________________________________
ASA classification: I I I I I I* IV* E If any * is medical consultation indicated? NO YES Date requested: ______________
Comments: _____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Is this patient a candidate for in-office sedation? YES NO Doctor’s signature: ______________________________ Date: ___________________
Plan Name/relation to patient Initials Date By

Informed consent for sedation obtained from ___________________________________ ________ _____________ ______________________
for protective stabilization obtained from ___________________________________ ________ _____________ ______________________
Pre-op instructions reviewed with ___________________________________ ________ _____________ ______________________
Post-op precautions reviewed with ___________________________________ ________ _____________ ______________________
Scheduled for: Date: _________________ Time: _____________________ with Dr.: ________________________
Assessment on Day of Sedation Date: ___________________

Accompanied by: ____________________________________ and ________________________ Relationships to patient: ________________________
Medical Hx & ROS update NO YES NPO status Airway assessment NO YES Safety checklist
Change in medical hx/ROS Clear liquids ____hrs Upper airway clear Monitors tested & functioning as intended
Change in medications Milk, other liquids, Lungs clear Emergency kit, suction, & high-flow oxygen
Recent respiratory illness &/or foods ____hrs Tonsillar obstruction (___%) No contraindication to procedural sedation
Pregnancy test indicated Medications ____hrs Weight: _____kg Height: _____cm BMI: _____ Two adults present or extended time for
Date: _______ Test: ________ Results: _________ discharge accepted
Vital signs (If unable to obtain, check and document reason: ______________________________________________________ )
Blood pressure: _______/_______ mmHg Respiration: _______/min Pulse: ________/min Temperature: _______oF SpO2: _______%
Comments: _____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Presedation cooperation level: Unable/unwilling to cooperate Rarely follows requests Cooperates with prompting Cooperates freely
Behavioral interaction: Definitively shy and withdrawn Somewhat shy Approachable
Guardian was provided an opportunity to ask questions, appeared to understand, and reaffirmed consent for sedation? YES NO
Drug Dosage Calculations

Sedatives
Agent ________________________________ Route ________ ________mg/kg X _______kg = ________mg 8_________mg/mL = _________mL
Emergency reversal agents
For narcotic: NALOXONE IV, IM, or subQ Dose: 0.1 mg/kg X _____ kg = ______mg (maximum dose: 2 mg; may repeat to maintain reversal)
For benzodiazepine: FLUMAZENIL IV (preferred), IM Dose: 0.01 mg/kg X _____ kg = ______mg (maximum dose: 0.2 mg; may repeat up to 4 times)
Local anesthetics (maximum dosage is based on weight; to calculate maximum volume, divide maximum dosage by agent concentration)
2% Lidocaine 4.4 mg/kg X _______ kg = ________ mg ÷ 20 mg/mL = _____ mL
4% Articaine 7 mg/kg X _______ kg = ________ mg ÷ 40 mg/mL = _____ mL
3% Mepivacaine 4.4 mg/kg X _______ kg = ________ mg ÷ 30 mg/mL = _____ mL
0.5% Bupivacaine 1.3 mg/kg X _______ kg = ________ mg ÷ 5 mg/mL = _____ mL
RESOURCES: SEDATION RECORD
Intraoperative Management and Post-Operative Monitoring EMS telephone number: ________________________

Timeout: Pt ID Agreement on procedure Tooth/surgical site _________________
Monitors: Observation Pulse oximeter Precordial/pretracheal stethoscope Blood pressure cuff Capnograph EKG Thermometer
Protective stabilization/devices: Papoose Head positioner Manual hold Neck/shoulder roll Mouth prop Rubber dam _______
TIME Baseline : : : : : : : : : : : : : : : :
1
Sedatives
N2O/O2 (%)
Local 2 (mg)
SpO2
Pulse
Blood pressure
Respiration
CO2
Procedure3
Comments4
Sedation level †
Behavior §
1. Agent ________________________________ Route _________ Dose _________ Time _________ Administered by ______________________
Agent ________________________________ Route _________ Dose _________ Time _________ Administered by ______________________
Agent ________________________________ Route _________ Dose _________ Time _________ Administered by ______________________
2. Local anesthetic agent ___________________________________________________
3. Record dental procedure start and completion times, transfer to recovery area, etc.
4. Enter letter on chart and corresponding comments (e.g., complications/side effects, airway intervention, reversal agent, analgesic) below:
A. __________________________________ B. __________________________________ C. ___________________________________
D. __________________________________ E. __________________________________ F. ___________________________________
† Sedation level § Behavior/responsiveness to treatment
None (typical response/cooperation for this patient) Excellent: quiet and cooperative
Minimal (anxiolysis) Good: mild objections &/or whimpering but treatment not interrupted
Moderate (purposeful response to verbal commands ± light tactile sensation) Fair: crying with minimal disruption to treatment
Deep (purposeful response after repeated verbal or painful stimulation Poor: struggling that interfered with operative procedures
General Anesthesia (not arousable) Prohibitive: active resistance and crying; treatment cannot be rendered
Overall effectiveness: Ineffective Effective Very effective Overly sedated
Additional comments/treatment accomplished: _________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Discharge
Criteria for discharge Discharge vital signs
Cardiovascular function is satisfactory and stable. Protective reflexes are intact. Pulse: ______/ min
Airway patency is satisfactory and stable. Patient can talk (return to presedation level). SpO2: ______%
Patient is easily arousable. Patient can sit up unaided (return to presedation level). BP: ______/______ mmHg
Responsiveness is at or very near presedation level State of hydration is adequate. Resp: ______/ min
(especially if very young or special needs child incapable of the usually expected responses) Temp: ______oF
Discharge process
Post-operative instructions reviewed with ________________________________________________ by ________________________________________
Transportation Airway protection/observation Activity Diet Nausea/vomiting Fever Rx Anesthetized tissues
Dental treatment rendered Pain Bleeding ______________________________ Emergency contact
Next appointment on: _______________________________________________________________ for _______________________________________
I have received and understand these discharge instructions. The patient is discharged into my care at _________ AM PM
Signature: ______________________________________ Relationship: ________________________ After hours number: _________________________
Operator Chairside Monitoring

Signature: _____________________________ Assistant: _______________________ Personnel Signature: __________________________
Post-op call
Date: ______________ Time: _________ By: _________ Spoke to: __________________________ Comments: _______________________________
______________________________________________________________________________________________________________________________
RESOURCES: POST-OP INSTRUCTIONS
Post-Operative Instructions for Extractions / Oral

Surgery
Patient: __________________________________________________________ Date: _________________________________
Your child had the following procedure performed today: U Extraction U Exposure of unerupted tooth
U Frenectomy U Biopsy U Gingivectomy U Gingival graft U Other: ___________________________________
This will require special care and attention over the next few days. Please follow the instructions checked below. Contact us with
questions or if unusual symptoms develop.
U Numbness: The mouth will be numb approximately two to four hours. Watch to see that your child does not bite, scratch,
or injure the cheek, lips, or tongue during this time.
U Bleeding: Bleeding was controlled before we discharged your child, but some occasional oozing (pink or blood-tinged saliva)
may occur. Hold gauze with firm pressure against the surgical site until oozing has stopped. You may need to change the gauze
or repeat this step. If bleeding continues for more than two hours, contact us.
U Surgical site care: Today, do not disturb the surgical site. Do not stretch the lips or cheeks to look at the area. Do not rinse
vigorously, use mouthwash, or probe the area with fingers or other objects. Beginning tomorrow, you may rinse with warm
salt water (½ teaspoon salt with one cup water) after meals.
U Sutures: Sutures (stitches) were placed to help control bleeding and promote healing. These sutures
U will dissolve and do not need to be removed OR U will be removed at your follow-up visit.
If the stitches come out during the first 48 hours, call our office.
U Daily activities: Today, avoid physical exercise and exertion. Return to normal activities as tolerated. Smoking is never good for
one’s health and may delay healing following oral surgery.
U Diet: After all bleeding has stopped, the patient may drink cool non-carbonated liquids but should NOT use a straw. Encourage
®
fluids to help avoid dehydration. Cold soft foods (e.g., ice cream, gelatin, Instant Breakfast , pudding, yogurt) are ideal the
first day. By the second day, consistency of foods can progress as tolerated. Until healing is more established, avoid foods such
as nuts, sunflower seeds, and popcorn that may get lodged in the surgical areas.
U Oral hygiene: Keeping the mouth clean is essential. Today, teeth may be brushed and flossed gently, but avoid stimulating
the surgical site. Soreness and swelling may not permit vigorous brushing of all areas, but please make every effort to clean the
teeth within the bounds of comfort.
U
®
Pain: Because some discomfort is expected, you may give your child acetaminophen (Tylenol ), naproxen (Aleve , Anaprox ,
® ®
® ® ®
Naprosyn ), or ibuprofen (Advil , Motrin ) before the numbness wears off. Do NOT give aspirin to your child. Follow the
instructions on the bottle for dosing based upon your child’s age/weight. If pain is not relieved by one of these medications, call
our office.
U Prescription: You were prescribed U pain medicine U antibiotics U oral rinse U other _______________________
Directions: ______________________________________________________________________________________________
________________________________________________________________________________________________________
U Other: ___________________________________________________________________________________________________
________________________________________________________________________________________________________
U Watch for:
U Swelling: Slight swelling and inflammation may occur for the next two days. If swelling occurs, ice packs may be used for the
first 24 hours (10 minutes on then 10 minutes off ) to decrease swelling and/or bruising. If swelling persists after 24 hours,
warm/moist compresses (10 minutes on then 10 minutes off) may help. If swelling occurs after 48 hours, call our office.
U Fever: A slight fever (temperature to 100.5° Fahrenheit) is not uncommon the first 48 hours after surgery. If a higher fever
develops or the fever persists, call our office.
U Dry socket: Premature dissolving or loss of a blood clot following removal of a permanent tooth may result in a dry socket. This
typically occurs on the third to fifth day after the extraction, with a persistent throbbing pain in the jaw. Call our office if this occurs.
U Follow-up: Schedule your child’s next visit for ____________________________________ in _________ days/weeks/months.
Contact numbers: Office: _________________________________________ After hours: __________________________________

RESOURCES: RECORD TRANSFER
Record Transfer
To: __________________________________ Date: _________________________
__________________________________
__________________________________
Re: Patient: ___________________________________________ Nickname: ______________________

DOB: _________________ Gender: ____________
Parent/Legal guardian: __________________________________________________________________
Special health care needs: No Yes ___________________________________________________
First encounter: ______________ Chief complaint: ____________________________________________

Last examination: _____________ Planned treatment: Completed Deferred Ongoing
Oral hygiene: Excellent Good Fair Poor Non-existent
Caries history: None Low Moderate High
Remarkable clinical findings: Radiographic history/date:

Developmental anomalies Bitewings _________________________________
Soft tissue pathology Panoramic ________________________________
Fluorosis Full mouth ________________________________
Nonnutritive habits Single tooth _______________________________
Malocclusion Cephalogram ______________________________
Traumatic injury Other ____________________________________
Other __________________________
Comments _______________________________________________________________________________
________________________________________________________________________________________
Professional preventive care: Management of developing occlusion:

Fluoride (last treatment _____________) Monitored eruption/growth
Sealants _________________________ Appliances ________________________________
Prescription fluoride/chlorhexidine Retention _________________________________
Dietary counseling Treatment completed ________________________
Comments _______________________________________________________________________________
________________________________________________________________________________________
Behavior: Cooperative Previous difficulties Ongoing considerations

Adjunctive techniques: Nitrous Sedation General anesthesia Other ___________________
Referral for specialty care: No Yes ______________________________________________________
Additional considerations: ___________________________________________________________________
________________________________________________________________________________________
Patient due for recall: ____________________ Recall frequency: ______________________
For additional information, please contact (_______) ___________________
_______________________________________ _________________________________________
Signature of person completing form Signature of attending dentist

RESOURCES: SCHOOL RELEASE FORM
Release for School Absences
A Message to Parents and School Administrators Regarding School Absence

for Dental Appointments
Tooth decay in children can be painful, just as it is in adults. Although largely preventable with proper home care
and regular dental visits, untreated tooth decay diminishes a child’s ability to eat, sleep, and function well at home
or at school. The unesthetic nature of tooth decay and dental malocclusion also may compromise the child’s self-
esteem and social development. Prevention, early diagnosis, and treatment of oral health conditions require pro-
fessional care.
The American Academy of Pediatric Dentistry recognizes the importance of regular school attendance and the
effect of chronic absence on academic performance. We encourage our members to work with parents and educa-
tors to minimize school absence whenever possible. It is not always possible or appropriate to provide all the care
children need during non-school hours. School policies that prevent legitimate school absence for the purpose
of dental visits may have a negative impact on the health and well being of children.
The American Academy of Pediatric Dentistry urges parents, school administrators, and member dentists to
work together to ensure that children receive needed health care while minimizing school absences. The American
Academy of Pediatric Dentistry encourages parents to return their children to school for the remainder of the day
after their dental visit when possible. In the case of an appointment later in the day, a child should attend school
and be excused prior to his/her dental appointment.
School Attendance Release
Student: _________________________________ had an appointment in this office on ______________________
from _______________ to ______________ for necessary oral health care.

RESOURCES: COMMON TESTS
Common Laboratory Values

CBC
Test Normal value Function Significance
Measures oxygen carrying capacity Low: hemorrhage, anemia
Hemoglobin 10.5-18 g/dL
of blood High: polycythemia
Measures relative volume of cells Low: hemorrhage, anemia
Hematocrit 32-52%
and plasma in blood High: polycythemia, dehydration
Measures oxygen-carrying capacity Low: hemorrhage, anemia
Red blood cell 4-6 million/mm3
of blood High: polycythemia, heart disease, pulmonary disease
White blood cell Measures host defense against Low: aplastic anemia, drug toxicity, specific infections
1-23 months 6,000-14,000/mm3 inflammatory agents High: inflammation, trauma, toxicity, leukemia
2-9 years 4,000-12,000/mm3
10-18 years 4,000-10,500/mm3
Differential Counts
Test Relative counts Absolute counts Significance
Neutrophils (segs) 54-62% 3,000-5,8000/mm3 Increase in bacterial infections, hemorrhage, diabetic acidosis
<1,000/mm3: patient at increased risk for infection – defer elective dental treatment
Neutrophils (bands) 3-5% 150-400/mm3 Increase in bacterial infections, trauma, burns, surgery, acute hemolysis or hemorrhage
3
Lymphocytes 25-30% 1,500-3,000/mm Viral and bacterial infections, acute and chronic lymphocytic leukemia, antigen reaction
Eosinophils 1-3% 50-250/mm3 Increase in parasitic and allergic conditions, blood dyscrasias, pernicious anemia
Basophils 0-0.75% 15-50/mm3 Increase in types of blood dyscrasias
3
Monocytes 3-7% 285-500/mm Hodgkin’s disease, lipid storage disease, recovery from severe infections, monocytic leukemia
Bleeding Screen
Prothrombin 12.7-15.4 sec Measures extrinsic clotting of blood Prolonged in liver disease, impaired Vitamin K production,
time surgical trauma with blood loss
Partial thrombo- By laboratory control Measures intrinsic clotting of blood, Prolonged in hemophilia A, B, and C and Von Willebrand’s
plastin time congenital clotting disorders disease
Platelets 150,000-400,000/mm3 Measures clotting potential Increased in polycythemia, leukemia, severe hemorrhage; decreased
in thrombocytopenia purpura
Bleeding time (adult) <7.1 min Measures quality of platelets Prolonged in thrombocytopenia
International Without anticoagulant Measures extrinsic clotting Increased with anticoagulant therapy
Normalized therapy: 1; Anticoagulant function
Ratio (INR) therapeutic range: 2-3
Urinalysis
Volume 1,000-2,000 mL/day Increased in diabetes mellitus, chronic nephritis
Specific gravity 1.015-1.025 Measures the degree of tubular Increased in diabetes mellitus; decreased in acute nephritis,
reabsorption and dehydration diabetes insipidus, aldosteronism
pH 5.0-9.0 Reflects acidosis and alkalosis Acidic: diabetes, acidosis, prolonged fever
Alkaline: urinary tract infection, alkalosis
Casts 1-2 per high power field Renal tubule degeneration occurring in cardiac failure, pregnancy,
and hemogobinuric-nephrosis
Electrolytes
Sodium (Na) 134-143 mmol/L Increased in Cushing’s syndrome
Potassium (K) 3.3-4.6 mmol/L Increased in tissue breakdown
Bicarbonate (HCO3) 22-29 mmol/L (venous) Reflects acid-base balance
21-28 mmol/L (arterial)
Chloride (Cl) 98-106 mmol/L Increased in renal disease and hypertension
Markers
Test Normal value Significance
C-reactive protein (CRP) 0.08-1.58 mg/dl Increase in infection; indicates an acute phase of the inflammatory
range is age dependent metabolic response
References
1. Kliegman RM, St Geme JW, Blum NJ, SHah SS, Tasker RC, WIlson KM, eds. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, Pa.: Elsevier; 2020.
2. Jameson JL, Kasper DL, eds. Harrison’s Principles of Internal Medicine, 20th ed. New York, N.Y.: Mc Graw-Hill; 2018.
RESOURCES: USEFUL MEDICATIONS
Useful Medications for Oral Conditions*

DISCLAIMER: Drug information is constantly changing and is often subject to interpretation. While care has been taken to ensure
the accuracy of the information presented, the AAPD is not responsible for the continued currency of the information, errors,
omissions, or consequences resulting from the use of these medications. Decisions about drug therapy must be based upon the
independent judgment of the clinician, changing drug information, and evolving healthcare practices.
* Pediatric dosage should not exceed adult dosage.
Analgesics
Mild / Moderate Pain1
Acetaminophen
Both acute and chronic doses of acetaminophen are associated with hepatotoxicity. For this reason, this drug has been reformulated so the
products are limited to 325 mg per dosage unit.
Forms: Liquid, tablet, oral disintegrating tablet, caplet, rectal suppository, injectable
Usual oral dosage:2,4
Children <12 years: 10-15 mg/kg/dose every 4-6 hours as needed (maximum 75 mg/kg/24 hours, but not to exceed 4.0 g/24 hours)
OR ALTERNATIVE DOSING BASED ON AGE OF CHILD 3

Age Weight Dosage
lbs kg mg3
0-3 months 6-11 2.7-5 40
4-11 months 12-17 5.1-7.7 80
1-2 years 18-23 7.8-10.5 120
2-3 years 24-35 10.6-15.9 160
4-5 years 36-47 16-21.4 240
6-8 years 48-59 21.5-26.8 320
9-10 years 60-71 26.9-32.3 400
11 years 72-95 32.4 - 43.2 480
Children >12 years and adults: 325-650 mg every 4-6 hours

OR 1,000 mg 3-4 times/day as needed (maximum 4 g/24 hours)
Ibuprofen
Forms: Liquid, tablet, injectable
Usual oral dosage:2-4
Infants and children <50 kg: 4-10 mg/kg/dose every 6-8 hours as needed (maximum single dose 400 mg; maximum dose 40 mg/kg/24 hours)
OR ALTERNATIVE DOSING BASED ON AGE OF CHILD 3

Age Weight Dosage
lbs kg mg
6-11 months 12-17 5.1-7.7 50
12-23 months 18-23 7.8-10.5 75
2-3 years 24-35 10.6-15.9 100
4-5 years 36-47 16-21.4 150
6-8 years 48-59 21.4-26.8 200
9-10 years 60-71 26.9-32.3 250
11 years 72-95 32.4 - 43.2 300
Children >12 years: 200 mg every 4-6 hours as needed (maximum 1.2 g/24 hours)
Adults: 200-400 mg/dose every 4-6 hours as needed (maximum 1.2 g/24 hours)

Naproxen
Dosage expressed as 200 mg naproxen base is equivalent to 220 mg naproxen sodium. For acute pain, naproxen sodium may be preferred
because of increased solubility leading to faster onset, higher peak concentration, and decreased adverse drug events.
Forms: Suspension, tablet
Usual dosage:2-4
Children and adolescents < 60 kg: 5-6 mg/kg every 12 hours as needed (maximum daily dose 1,000 mg/day)
Children and adolescents >60 kg: 250-375 mg every 12 hours as needed (maximum daily dose 1,000 mg/day)
Adults: Initial dose of 500 mg, then 250 mg every 6-8 hours as needed (maximum 1,250 mg/day)
Moderate/Severe Pain
The use of codeine and its alternatives, oxycodone, hydrocodone, morphine, and tramadol, for children as an analgesic is not recommended
by the American Academy of Pediatrics.5 Recently, an overview of the benefits and risks of analgesic medications for the management
of acute dental pain has been summarized.6
Systemic Antibiotics
Amoxicillin
Forms: Suspension, chewable tablet, tablet, capsule
Infants >3 months, children, and adolescents <40 kg: 20-40 mg/kg/day in divided doses every 8 hours (maximum 500 mg/dose)
OR 25-45 mg/kg/day in divided doses every 12 hours (maximum 875 mg/dose)
Adolescents and adults: 250-500 mg every 8 hours
OR 500-875 mg every 12 hours
Endocarditis prophylaxis:3,4,7 50mg/kg (maximum 2 g) 30-60 minutes before procedure
Amoxicillin clavulanate potassium

Use the lowest dose of clavulanate combined with amoxicillin available to decrease gastrointestinal adverse drug events.
Forms: Suspension, chewable tablet, tablet
Usual oral dosage:2-4 (based on amoxicillin component):
Children >3 months of age up to 40 kg: 25-45 mg/kg/day in doses divided every 12 hours (maximum single dose 875 mg)
(prescribe suspension or chewable tablet due to clavulanic acid component)
Children >40 kg and adults: 500-875 mg every 12 hours (prescribe tablet)
Azithromycin
This drug is one of two options for patients with Type I allergy to penicillin and/or cephalosporin antibiotics.
Caution: This drug can cause cardiac arrhythmias in patients with pre-existing cardiac conduction defects.
Forms: Tablet, capsule, suspension, injectable
Usual oral dosage:2-4 (Note: Doses may vary for extended release suspension depending on the reason for prescribing the antibiotic.)
Children >6 months up to 16 years: 5-12 mg/kg on day 1, single dose, (maximum 500 mg/day), followed by 5-6 mg/kg once daily
for remainder of treatment (2-5 days)
Adults: 500 mg on day 1, single dose, followed by 250 mg daily as a single dose for 2-5 days
Endocarditis prophylaxis:3,4,7 15 mg/kg (maximum 500 mg) 30-60 minutes before procedure
Cephalexin
Caution: This antibiotic should not be prescribed to patients with Type I allergic reactions to penicillin antibiotics.
Forms: Suspension, tablet, capsule
Children >1 year: 25-100 mg/kg/day in divided doses every 6-8 hours (maximum 4g/day)
Adults: 250-1,000 mg every 6 hours (maximum 4 g/day)
Endocarditis prophylaxis:3,4,7 50 mg/kg (maximum 2 g) 30-60 minutes before procedure

Clindamycin
Note: This is one of two options for patients with Type I allergic reactions to penicillin and/or cephalosporin antibiotics. This antibiotic
is effective for infections (e.g., abscesses) with gram-positive aerobic bacteria and gram-positive or gram-negative anaerobic bacteria.
Forms: Suspension, capsule, injectable
Children: 8-20 mg/kg/day in 3-4 divided doses as hydrochloride
OR 8-25 mg/kg/day in 3-4 divided doses as palmitate
Adults: 150-450 mg every 6 hours (maximum 1.8 g/day)
Endocarditis prophylaxis:3,4,7 20 mg/kg (maximum 600 mg) 30-60 minutes before procedure
Doxycycline
Important: This drug may cause permanent tooth discoloration, enamel hypoplasia in developing teeth, and hyperpigmentation of the soft
tissues. Due to these and other side effects, women who are pregnant and children <8 years old should not use this drug.
Forms: Suspension, tablet, delayed release tablet, capsule, injectable
Usual oral dosage for necrotizing ulcerative gingivitis:2-4
Children >8 years who weigh <45 kg: 2.2 mg/kg every 12 hours on day 1, then 2.2 mg/kg once/day; for severe infections, 2.2 mg/kg
every 12 hours until infection resolves
Children >8 years who weigh >45 kg and adults: 100 mg every 12 hours on day 1, then 100 mg once/day; for severe infections, 100 mg
every 12 hours until infection resolves
Metronidazole
Important: Metronidazole is a useful addition to an antibiotic regimen when coverage of anaerobic bacteria is needed. Patients should
avoid ingestion of alcohol as a beverage or ingredient in medications while taking metronidazole.
Forms: Tablet, tablet extended release, capsule, injectable
Usual oral dosage:
For anaerobic skin and bone infection:2-4
Children: 30/mg/kg/day in divided doses every 6 hours (maximum 4 g/24 hours)
Adolescents and adults: 7.5 mg/kg every 6 hours (maximum 4 g/24 hours)
For periodontal disease, including necrotizing ulcerative gingivitis:2,4
Adolescents and adults: 250 mg every 6-8 hours for 10 days in combination with amoxicillin
For aggressive oral infections, may be used in combination with amoxicillin:
250 mg 3 times/day with amoxicillin (250-375 mg 3 times/day) for 7-10 days
Penicillin V Potassium
Caution: The practitioner should use penicillin cautiously in patients with renal impairment or history of seizures. Anaphylactic reactions
have been demonstrated in patients receiving penicillin, most notably those with a history of beta-lactam hypersensitivity, sensitivity to
multiple allergens, or prior IgE-mediated reactions (e.g., angioedema, urticaria, anaphylaxis).3 This antibiotic should be taken on an empty
stomach because it is degraded by acid and enzyme activity in the stomach associated with ingestion of food.
Forms: Liquid, tablet
Children <12 years: 25-50 mg/kg/day in divided doses every 6-8 (maximum 3 g/day)
Children >12 years and adults: 250-500 mg every 6-8 hours
Systemic Antifungal Agent for Oral Candidiasis

Fluconazole
Important: The drug requires acidic pH in the stomach to disintegrate and dissolve for oral absorption; therefore, absorption is decreased by
medications that increase gastric pH. Also, prescribe with caution for patients taking other medications metabolized by CYP enzymes because
fluconazole is a hepatic enzyme inhibitor.
Form: Suspension 10 mg/mL, 40 mg/mL; tablet: 50 mg, 100 mg, 150 mg, 200 mg; injectable 200 mg, 400 mg
Usual dosage:2-4
Neonates >14 days: Single dose of 6 mg/kg on day 1; then decrease to 3 mg/kg once/day for 7 to 14 days
Adolescents and adults: Single dose of 200 mg on day 1; then decrease to 100 mg once/day for 14 days

Topical Antifungal Agents

Topical agents for angular cheilitis
Clotrimazole
Form: Cream 1%
Usual dosage:2
All ages: Apply a thin layer to the corners of the mouth 4 times/day for 14 days or until complete healing.
Miconazole nitrate
Forms: Ointment 2%; cream 2%
Usual dosage:2
Children >2 years and adults: Apply a thin layer to the corners of the mouth 4 times/day for 14 days or until complete healing.
Nystatin
Forms: Ointment, cream (100,000 units/g)
Usual dosage:2
For all ages: Apply a thin layer to angles of mouth 4 times/day for 14 days or until complete healing.
Nystatin, triamcinolone acetonide (not FDA-approved for this use)

Forms: Ointment, cream (100,000 units nystatin/g and 0.1% triamcinolone acetonide)
Usual dosage:2 (Note: Not for use in patients <2 months of age.)
Apply a thin layer to the angles of the mouth 4 times/day for no longer than 2 weeks.
Topical or transmucosal agents for oral candidiasis

Clotrimazole
Form: Lozenge 10 mg
Usual dosage:2,3 (Note: Not for use in patients <3 years of age.)
Dissolve one troche 5 times/day for 14 days. Treatment may extend beyond clinical resolution.
Miconazole (Oravig )
®
Form: Buccal tablet 50 mg
Usual dosage:2-4
Adolescents >16 years and adults: One tablet/day for 14 days; apply to the gum region, just above the upper lateral incisor.
Nystatin
Form: Suspension (100,000 units/mL)
Usual oral dosage:2,4
Infants: 200,000 - 400,000 units (2-4 mL) 4 times/day; ½ of dose placed in each side of mouth
Children and adults: Swish 400,000-600,000 units (4-6 mL) 4 times/day for several minutes and swallow; continue
at least 48 hours after symptoms resolve
Systemic Antiviral Agents

Systemic agent for primary herpetic gingivostomatitis
Acyclovir (not FDA-approved for this use)
Forms: Suspension 200 mg/5 mL; tablets 400 mg, 800 mg; capsules 200 mg; injectable 50 mg/mL
Usual dosage:3,4
Children: 15 mg/kg 5 times/day for 7 days (maximum 200 mg/dose)
Immunocompromised children: 1,000 mg/day orally in 3-5 divided doses for 7-14 days (maximum 80 mg/kg/day)
Adolescents and adults: 400 mg 3-5 times/day for 10 days or until clinical resolution occurs
OR 800 mg every 8 hours for 7-10 days
OR 200-400 mg 5 times/day for 10 days

Systemic agents for herpes labialis

Acyclovir (not FDA-approved for this use)
Form: Suspension 200 mg/5 mL; tablets 400 mg, 800 mg; capsules 200 mg; injectable 50 mg/mL
Usual dosage:2-4 (Begin treatment at the earliest signs/symptoms)
Infants and Children: 20 mg/kg/dose 4 times/day for 5 days (maximum 400 mg/dose)
Immunocompromised children: 1,000 mg/day orally in 3-5 divided doses for 7-14 days (maximum 80 mg/kg/day)
Adolescents and adults: 400 mg three times/day for 5 days
OR 200 mg 5 times/day (approximately every 4 hours) for 5 days
OR 800 mg 2 times/day for 5 days
Famciclovir
Form: Tablet 125 mg, 250 mg, 500 mg
Usual dosage: 2-4
Children: Safety and efficacy have not been established.
Adolescents and adults: 1,500 mg as a single dose at the first sign or symptom of infection (maximum has not been established for
adolescents; maximum 2 g/day orally for adults for one-day regimens or 1,500 mg/day orally for multiple-
day regimens)
Valacyclovir
Form: Tablet 500 mg, 1 g
Children 12 years and adults: 2 g for 2 doses, 12 hours apart (maximum 4 g/day for one-day regimens or 3 g/day for multiple-day
regimens)
Topical Agents for Herpes Labialis

Docosanol (Abreva® – over-the-counter agent)
Form: Cream 10%
Usual dosage:2-4
Children 12 years and adults: Apply a thin layer on the lesion 5 times/day for up to 10 days.
Acyclovir
Form: Cream 5%
Usual dosage:2-4
Children 12 years and adults: Apply a thin layer on the lesion 5 times/day for 4 days.
Acyclovir (minimal absorption)

Important: Contains milk protein concentrate.
Form: Buccal tablet 50 mg
Usual dosage:2-4
Children 12 years and adults: Apply 1 tablet one time to the upper gums in area of canine fossa.
Acyclovir with hydrocortisone (Xerese ) ®

Form: Cream (5% acyclovir with 1% hydrocortisone)
Usual dosage:2-4
Children 6 years and adults: Apply a thin layer on the lesion 5 times/day for 5 days.
Penciclovir
Form: Cream 1%
Usual dosage:2-4
Children 12 years and adults: Apply a thin layer on the lesion every 2 hours while awake for 4 days.

Topical Anti-inflammatory/Coating Agent

Diphenhydramine hydrochloride and aluminum hydroxide, magnesium hydroxide, simethicone (not FDA-approved
for this use)
Important: This suspension may be compounded with viscous lidocaine (2% solution) for a greater topical anesthetic effect. There is a
potential for lidocaine toxicity if oral suspension is overused, and there is an increased risk for aspiration if used in children who cannot
expectorate.
Form: Suspension [needs to be compounded by pharmacist; 50/50 mixture of liquid diphenhydramine hydrochloride (12.5 mg/5 mL)
with aluminum hydroxide, magnesium hydroxide, simethicone suspension]
Usual dosage:2-4
Children and adults: Rinse with 5-10 mL every 2-4 hours for 2 minutes and expectorate.
Note: Maximum dose of diphenhydramine hydrochloride in case the suspension is swallowed:
Children 2 to <6 years: 37.5 mg/day
Children 6 to <12 years: 150 mg/day
Children ≥12 years: 300 mg/day
Adults: 400 mg/day
Topical Antibacterial/Antimicrobial Agents

Chlorhexidine gluconate
Forms: Dental solution 0.12% (Note: Most brands contain alcohol.)
Usual dosage for gingivitis/periodontitis and stomatitis (off label use for stomatitis):2-4
Children 8 years and adults: Rinse with 15 mL 2 times/day (after breakfast and before bed) for 30 seconds and expectorate.
Mupirocin
Forms: Ointment 2%; cream 2%
Usual dosage for localized impetigo or skin infection:2-4 (Note: For external use only; not for use in patients <2 months of age)
Apply a small amount of ointment to the affected area 3 times/day. Treatment usually is continued for 1-2 weeks
Retapamulin
Forms: Ointment 1%
Usual dosage for localized impetigo:2-4 (Note: For external use only; limited information on age group 1 to <9 months of age)
Apply a small amount of ointment to the affected area 2 times/day for 5 days.
Topical Corticosteroids for Aphthous Ulcers

Triamcinolone acetonide (a medium potency corticosteroid)
Form: Dental paste
Usual dosage:2
Adolescents and adults: Apply paste to ulcers 3 times/day, after meals and at bedtime; not to exceed 7 day course.
Fluocinonide (a high potency corticosteroid; not FDA-approved for oral application)

Form: Gel, ointment 0.05%
Usual dosage:2
Adolescents and adults: Apply thin amount of gel or ointment to ulcers 2-4 times a day; not to exceed 7 day course.
Dexamethasone (a high potency corticosteroid; not FDA-approved for oral application)

Form: Elixir, solution (contains alcohol)
Usual dosage:2
Adolescents and adults: Rinse with 5 mL 4 times/day for 2 minutes and expectorate; not to exceed 7 day course.

Clobetasol (a super-high potency corticosteroid; not FDA-approved for oral application)

Form: Gel, ointment 0.05%
Usual dosage:2
Adolescents and adults: Apply thin amount of gel or ointment to ulcers 2-4 times/day, not to exceed 7 day course.
References
1. American Academy of Pediatric Dentistry. Policy on acute pediatric dental pain management. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:121-3.
2. Jeske AH. Mosby’s Dental Drug Reference. 12th ed. St. Louis, Mo.: Elsevier, Inc.; 2018.
3. Lexicomp Online, Pediatric and Neonatal Lexi-Drugs Online. Hudson, Ohio: Wolters Kluver Clinical Drug Information,
Inc.; 2020. Available at: “http://webstore.lexi.com/Pediatric-Lexi-Drugs”. Accessed October 12, 2020.
4. Lexicomp Online, Lexi-Drugs Online. Hudson, Ohio: Wolters Kluver Clinical Drug Information, Inc.; 2020. Available
at: “http://www.wolterskluwercdi.com/lexicomp-online/”. Accessed October 12, 2020.
5. Tobias JD, Green TP, Cote CJ, Section on Anesthesiology and Pain Medicine, AAP Committee on Drugs. Codeine: Time
to say “no”. Pediatrics 2016;138(4):e20162396.
6. Moore PA, Ziegler KM, Lipman RD, et al. Benefits and harms associated with analgesic medications used in the
management of acute dental pain. An overview of systematic reviews. J Am Dent Assoc 2018;149(4):256-68.
7. Wilson W. Taubery KA, Gewitz, et al. Prevention of infective endocarditis: Guidelines from the American Heart
Association. Circulation 2007;116(15):1736-54. Correction: Circulation 2007;116:e376-e377.

RESOURCES: SARS-CoV-2
Severe Acute Respiratory Syndrome Coronavirus 2 Transmission

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission continues to be a community and global problem requiring
implementation of public health initiatives and impacting oral health care delivery. The American Academy of Pediatric Dentistry (AAPD)
recognizes the importance of infection control policies, procedures, and practices in health care settings to prevent disease transmission.
Safety of the patient and dental team is an essential component of oral health care. Occupational risk of COVID-19 infection, the disease
caused by SARS-CoV-2, for dental professionals has been reported to be controlled by infection control procedures.1 Practitioners should use
a combination of standard, contact, and droplet precautions2 when performing patient care. The AAPD encourages dentists to follow current
research and best practices in infection control and to consult state and local regulatory agencies for recommendations to minimize risk of
SARS-CoV-2 transmission.
Because the issues and understanding of SARS-CoV-2 continue to evolve, the AAPD offers two online resource hubs:
• COVID-19 Updates and Resources (https://www.aapd.org/about/about-aapd/news-room/COVID-19/) provides links to resources that
promote safety and best practices in pediatric oral health care and maintenance of a dental home relative to the COVID-19 pandemic.
• The original Re-emergence Pediatric Dentistry Practice Checklist (https://www.aapd.org/globalassets/media/covid-19/aapd-practice
checklist.pdf ) has been supplemented by the hub (https://www.aapd.org/about/about-aapd/news-room/aapd-practice-checklist-resources/)
to guide re-entry into practices during the pandemic.
The following links are considered primary sources of information regarding SARS CoV-2/COVID-19:
COVID-19: Status Updates and Information Pages

• Centers for Disease Control and Prevention (CDC) Coronavirus COVID-19 is the CDC’s COVID-19 resource hub featuring
individual pages on a wide range of pandemic topics (https://www.cdc.gov/coronavirus/2019-ncov/index.html).
• Johns Hopkins University Coronavirus Resource Center provides daily updates, cases and trends by United States counties and
globally, and more (https://coronavirus.jhu.edu/).
• American Dental Association Coronavirus (COVID-19) Center for Dentists is a curated website of infection control and practice tools
(including the Return to Work Interim Guidance Toolkit and COVID-19 Hazard Assessment Guide and Checklist), research, and
news (https://success.ada.org/en/practice-management/patients/infectious-diseases-2019-novel-coronavirus).
• Centers for Medicare and Medicaid Services (CMS) Coronavirus Disease 2019 provides links to clinical and technical guidance on
health care practice during the COVID-19 pandemic (https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/
Current-Emergencies/Current-Emergencies-page).
• Food and Drug Administration Coronavirus Disease 2019 (COVID-19) covers topics such as emergency authorization of medical
products, vaccines, and personal protective equipment (https://www.fda.gov/emergency-preparedness-and-response/counterterrorism-and
-emerging-threats/coronavirus-disease-2019-COVID-19).
• Morbidity and Mortality Weekly Report (MMWR): Novel Coronavirus Reports is dedicated to SARS-CoV-2 in the MMWR
(https://www.cdc.gov/mmwr/Novel_Coronavirus_Reports.html).
• American Academy of Pediatrics Critical Updates on COVID-19 offers practice advice, research, and news related to COVID-19 and
children’s health (https://services.aap.org/en/pages/2019-novel-coronavirus-COVID-19-infections/).
• World Health Organization provides an international perspective on Coronavirus Disease (https://www.who.int/health-topics/corona
virus#tab=tab_1) and the COVID-19 Pandemic on a global scale (https://www.who.int/emergencies/diseases/novel-coronavirus-2019).
COVID-19: Infection Control Tools and Readings

• CDC Guidance for Dental Settings: Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19
Pandemic (https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html).
• Occupational Safety and Health Administration COVID-19 Control and Prevention: Dentistry Workers and Employers (https://
www.osha.gov/SLTC/covid-19/dentistry.html) and Guidance on Preparing Workplaces for Covid-19 (https://www.osha.gov/Publications
/OSHA3990.pdf ).
• Environmental Protection Agency List N: Disinfectants for Coronavirus (COVID-19) (https://www.epa.gov/pesticide-registration/list
-n-disinfectants-coronavirus-covid-19).
• Organization for Safety, Asepsis and Prevention/DentaQuest Partnership for Oral Health Advancement Best Practices for Infection
Control in Dental Clinics During the COVID-19 Pandemic (https://cdn.ymaws.com/www.osap.org/resource/resmgr/dentaquest/INC
-1353_Best_Practices_for_.pdf ).
• American Society of Dental Anesthesiologists Coronavirus Resources (https://asda.org/COVID-19-pandemic/).
• Cochrane: Recommendations for the re-opening of dental services: a rapid review of international sources (https://oralhealth.cochrane.
org/sites/oralhealth.cochrane.org/files/public/uploads/COVID19_dental_reopening_rapid_review_07052020.pdf ).
• CDC Scientific Brief: SARS-CoV-2 and Potential Airborne Transmission (https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-
brief-sars-cov-2.html).
• Scottish Dental Clinical Effectiveness Programme Mitigation of aerosol generating procedures in dentistry: A rapid review (https://
www.sdcep.org.uk/published-guidance/COVID-19-practice-recovery/rapid-review-of-agps/).
References
1. Nardone, M, Cordone, A, Petti, S. Occupational COVID‐19 risk to dental staff working in a public dental unit in the outbreak
epicenter. Oral Dis 2020;00:1-13. Available at: “https://doi.org/10.1111/odi.13632”. Accessed October 12, 2020.
2. Harte JA. Standard and transmission-based precautions in dentistry. J Am Dent Assoc 2010;141(5):572-81. Available at: “https://
germiphene.com/wp-content/uploads/2015/01/Standard-Transmission-based-Precautions-JADA.pdf
THE REFERENCE”. Accessed
MANUAL OctoberDENTISTRY
OF PEDIATRIC 12, 2020. 599
RESOURCES: MEDICAL EMERGENCIES
Management of Medical Emergencies

For all emergencies
1. Discontinue dental treatment 4. Monitor vital signs
2. Call for assistance / someone to bring oxygen and emergency kit 5. Be prepared to support respiration, support circulation, provide CPR, and call
3. Position patient: ensure open and unobstructed airway for emergency medical services
Condition Signs and symptoms Treatment Drug dosage Drug delivery*
Allergic reaction Hives; itching; edema; 1. Discontinue all sources of allergy-causing Diphenhydramine 1 mg/kg Oral
(mild or delayed) erythema–skin, substances Child: 10-25 mg q.i.d.
mucosa conjuctiva 2. Administer diphenhydramine Adult: 25-50 mg q.i.d.1
Allergic reaction Urticaria-itching, flushing, This is a true, life-threatening emergency Epinephrine 1:1000 IM or SubQ
(sudden onset): hives; rhinitis; 1. Call for emergency medical services 0.01 mg/kg every 5 minutes
anaphylaxis wheezing/difficulty breathing; 2. Administer epinephrine until recovery or until
bronchospasm; laryngeal 3. Administer oxygen help arrives1,2
edema; weak pulse; marked 4. Monitor vital signs
fall in blood pressure; loss of 5. Transport to emergency medical facility
consciousness by advanced medical responders
Acute asthmatic Shortness of breath; 1. Sit patient upright or in a 1. Albuterol (patient’s or Inhale
attack wheezing; coughing; comfortable position emergency kit inhaler)
tightness in chest; 2. Administer oxygen 2. Epinephrine 1:1000 IM or SubQ
cyanosis; tachycardia 3. Administer bronchodilator 0.01 mg/kg every
4. If bronchodilator is ineffective, administer 15 minutes as needed1,2
epinephrine
5. Call for emergency medical services with
transportation for advanced care if
indicated
Local anesthetic Light-headedness; changes 1. Assess and support airway, breathing, Supplemental oxygen Mask
toxicity in vision and/or speech; and circulation (CPR if warranted)
metallic taste; changes in 2. Administer oxygen
mental status–confusion; 3. Monitor vital signs
agitation; tinnitis; tremor; 4. Call for emergency medical services with
seizure; tachypnea; transportation for advanced care if
bradycardia; unconsciousness; indicated
cardiac arrest
Local anesthetic Anxiety; tachycardia/ 1. Reassure patient Supplemental oxygen Mask

reaction: palpitations; restlessness; 2. Assess and support airway, breathing, and
vasoconstrictor headache; tachypnea; circulation (CPR if warranted)
chest pain; cardiac arrest 3. Administer oxygen
4. Monitor vital signs
5. Call for emergency medical services with
transportation for advanced care if
indicated
Overdose: Somnolence; confusion; 1. Assess and support airway, breathing, and Flumazenil 0.01 - 0.02 mg/kg IV (if IV access
benzodiazepine diminished reflexes; circulation (CPR if warranted) (maximum: 0.2 mg); may is not available,
respiratory depression; 2. Administer oxygen repeat at 1 minute intervals may be given IM)
apnea; respiratory arrest; 3. Monitor vital signs not to exceed a cumulative
cardiac arrest 4. If severe respiratory depression, establish dose of 0.05 mg/kg or
IV access and reverse with flumazenil 1 mg, whichever is lower)1
5. Monitor recovery (for at least 2 hours
after the last dose of flumazenil) and call
for emergency medical services with
transportation for advanced care if indicated

RESOURCES: MEDICAL EMERGENCIES
For all emergencies

1. Discontinue dental treatment 4. Monitor vital signs
2. Call for assistance / someone to bring oxygen and emergency kit 5. Be prepared to support respiration, support circulation, provide CPR, and call
3. Position patient: ensure open and unobstructed airway for emergency medical services
Condition Signs and symptoms Treatment Drug dosage Drug delivery*
Overdose: Decreased responsiveness; 1. Assess and support airway, breathing, and Naxolone 0.1 mg/kg up IV, IM, or SubQ
narcotic respiratory depression; circulation (CPR if warranted) to 2 mg.1,2 May be
respiratory arrest; 2. Administer oxygen repeated to maintain
cardiac arrest 3. Monitor vital signs reversal.
4. If severe respiratory depression, reverse with
naxolone
5. Monitor recovery (for at least 2 hours after
the last dose of naxolone) and call for
emergency medical services with transpor-
tation for advanced care if indicated
Seizure Warning aura–disorientation, 1. Recline and position to Diazepam IV

blinking, or blank stare; prevent injury Child up to 5 yrs:
uncontrolled muscle 2. Ensure open airway and 0.2-0.5 mg slowly
movements; muscle rigidity; adequate ventilation every 2-5 minutes with
unconsciousness; postictal 3. Monitor vital signs maximum=5 mg
phase–sleepiness, confusion, 4. If status is epilepticus, give diazepam and Child 5 yrs and up:
amnesia, slow recovery call for emergency medical services with 1 mg every 2-5 minutes
transportation for advanced care if indicated with maximum=10 mg1
Syncope Feeling of warmth; skin pale 1. Recline, feet up Ammonia in vials Inhale
(fainting) and moist; pulse rapid 2. Loosen clothing that may be binding
initially then gets slow and 3. Ammonia inhales
weak; dizziness; hypotension; 4. Administer oxygen
cold extremities; 5. Cold towel on back of neck
unconsciousness 6. Monitor recovery
* q.i.d. = four times a day; IM = intramuscular; IV = intravenous; SubQ = subcutaneous; CPR = cardiopulmonary resuscitation.
References:
1. Hegenbarth MA, Committee on Drugs. Preparing for Pediatric Emergencies: Drugs to Consider, American Academy of Pediatrics. Pediatrics
2008;121(2):433-43.
2. Pediatric Advanced Life Support: 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardio-
vascular Care. Circulation 2015;132:S526-542.
DISCLAIMER: This information is not intended to be a comprehensive list of all medications that may be used in all emergencies. Drug information is
constantly changing and is often subject to interpretation. While care has been taken to ensure the accuracy of the information presented, the AAPD is not
responsible for the continued currency of the information, errors, omissions, or the resulting consequences. Decisions about drug therapy must be based
upon the independent judgment of the clinician, changing drug information, and evolving healthcare practices.

RESOURCES: BLS / CPR CHART
Basic Life Support / Cardiopulmonary Resuscitation
Reprinted with permission

Basic Life Support Provider Manual
© 2020, American Heart Association, Inc.

RESOURCES: PEDIATRIC DENTIST PRIVILEGES
Delineation of Privileges
Standard Hospital Privilege Form
Hospitals and ambulatory surgery centers require credentialing of dentists and delineation of pediatric dentistry privileges
to ensure quality patient care and to protect the patient from unqualified or incompetent practitioners. The American
Academy of Pediatric Dentistry suggests that the following qualifications and core privileges best characterize the training,
experience, and competence of an educationally-qualified pediatric dentist.
Qualifications
Granting privileges in pediatric dentistry requires a review of an individual’s qualifications that are evidenced, in part, by:
• Basic Education. DDS, DMD, or equivalent;
• Training. Successful completion of a pediatric dentistry residency program accredited by the American Dental
Association;
• Experience. Reflects the skills of an educationally-qualified, board candidate/board certified pediatric dentist.
Scope of practice includes primary and comprehensive preventive and therapeutic oral health care for infants
and children through adolescence. Treatment also may be provided to patients beyond the age of majority who
demonstrate physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment conditions
that require specialized care; and
• Certification. May be granted by the American Board of Pediatric Dentistry.
Privileges
Privileges included in the pediatric dentistry core may include, but are not limited to:
• Admissions and consultations. Inpatient and outpatient care including ward, operating and procedure rooms,
and emergency department settings.
• Diagnostic services and oral medicine. Orofacial examination, oral and maxillofacial radiography, diagnosis
and management of oral and perioral lesions and anomalies, pulp testing, treatment of common oral diseases,
uncomplicated biopsies and adjunctive diagnostic tests (e.g., exfoliative cytology, microbial cultures, Mutans
Streptococcus testing, other laboratory testing), impressions for dental models, caries risk assessment, assessment
and documentation of oral/dental neglect/abuse.
• Preventive procedures. Dental prophylaxis, dietary counseling, injury prevention counseling, sealant application,
fluoride therapies, silver diamine fluoride application, mouthguards/occlusal guards, anticipatory guidance,
counseling for tobacco and substance use/abuse cessation.
• Restorative dentistry and oral rehabilitation. Comprehensive restorative care including fixed and removable
prosthetic techniques for the primary, mixed, and permanent dentitions; cleft palate, maxillofacial, and speech
prostheses; dental bleaching, microabrasion, and esthetic restorations
• Management of the developing dentition and occlusion/orthodontic procedures. Treatment of non-nutritive
oral habits, space maintenance, space regaining, correction of dental crossbites and functional shifts, headgear,
functional appliances, fixed appliance therapy, infant maxillary orthopedics, orthodontic treatment in conjunc-
tion with orthognathic surgery, temporomandibular joint procedures of orthodontic nature, occlusal adjustment.
• Trauma/emergency procedures. Evaluation, diagnosis, and treatment of trauma to the primary, mixed, and
permanent dentitions (e.g., repositioning, replantation, and stabilization of intruded, extruded, luxated, and
avulsed teeth; restoration of complicated and uncomplicated dental fractures) and to the pulpal, periodontal, and
associated soft tissues, the dental alveolus, and orofacial soft tissues; treatment of infections of the maxillofacial
region by surgical and medical therapy; treatment of mouth burns.

• Periodontal procedures. Periodontal probing, gingival curettage, scaling, root planing, local or systemic chemo-
therapy, dental splinting, frenectomy (including correction of ankyloglossia), gingivectomy, gingival grafts.
• Endodontic procedures. Pulp capping, pulpotomy, pulpectomy and root filling of primary and permanent teeth;
pulp revascularization, apexification, apexogenesis, apicoectomy; management of periradicular tissues.
• Anesthesia and pain control. Local anesthesia of intraoral and perioral tissues; nitrous oxide/oxygen analgesia/
anxiolysis; minimal, moderate, or deep sedation; pain management by systemic chemotherapeutic agents.
• Oral and maxillofacial surgery procedures. Extractions of erupted teeth, surgical exposure and/or removal
of impacted or unerupted teeth, management of pericornitis, implant placement, autogenous tooth transplantation
biopsy of lesions, incision and drainage, removal of minor cysts and foreign bodies.
• Additional or special procedures. List procedures (e.g., laser surgery, implants) and qualifications:

RESOURCES: NOTES
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RESOURCES: NOTES
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The

211 East Chicago Avenue, Suite 1600

ISBN 978-1-7334978-2-4 (print)

Soraya M. Beiraghi Gajanan V. Kulkarni

Oral Health Policies

4 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

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Overview How to Cite: American Academy of Pediatric Dentistry. Overview.

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8 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

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The American Academy of Pediatric Dentistry

Vision • Support and promote programs that provide care to

Mission Workforce and Practice Transformation

10 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

Operations • Help volunteer leadership concentrate on issues by

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 11

The American Academy of Pediatric Dentistry

12 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

14 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

Definition of Dental Home

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Definition of Dental Neglect

16 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

Definition of Dental Disability

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Definition of Medically-Necessary Care

18 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

Definition of Special Health Care Needs

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Oral health policies

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Policy on Medically-Necessary Care

Purpose and all stakeholders should recognize that cost-effective care

22 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

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Policy on Social Determinants of Children’s Oral

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Policy on Care for Vulnerable Populations

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Policy on Oral Health Care Programs for Infants,

Purpose families was 18 percent while that of children from low-income

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40 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

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Policy on the Dental Home

Purpose Referral by the primary care physician or health provider has

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Policy on Workforce Issues and Delivery of Oral